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Langreen S, Ludwikowski B, Dingemann J, Ure BM, Hofmann AD, Kuebler JF. Laparoscopic pyeloplasty in neonates and infants is safe and efficient. Front Pediatr 2024; 12:1397614. [PMID: 39132308 PMCID: PMC11310035 DOI: 10.3389/fped.2024.1397614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 07/16/2024] [Indexed: 08/13/2024] Open
Abstract
Introduction Dismembered laparoscopic pyeloplasty (LP) is a well-accepted treatment modality for ureteropelvic junction obstruction (UPJO) in children. However, its efficacy and safety in infants, particularly neonates, remain uncertain. To address this significant knowledge gap, we aimed to compare outcomes between a cohort of neonates and infants undergoing LP vs. open pyeloplasty (OP) at less than 6 months and 6 weeks of age. Material and methods We conducted a retrospective analysis of data from patients who underwent primary pyeloplasty at our institution between 2000 and 2022. Only patients aged 6 months or less at the time of surgery were included, excluding redo-procedures or conversions. Ethical approval was obtained, and data were assessed for redo-pyeloplasty and postoperative complications, classified according to the Clavien-Madadi classification. A standard postoperative assessment was performed 6 weeks postoperatively. This included an isotope scan and a routine ultrasound up to the year 2020. Results A total of 91 eligible patients were identified, of which 49 underwent LP and 42 underwent OP. Patients receiving LP had a median age of 11.4 (1-25.4) weeks, compared to 13.8 (0.5-25.9) weeks for those receiving OP (p > 0.31). Both groups in our main cohort had an age range of 0-6 months at the time of surgery. Nineteen patients were younger than 6 weeks at the time of surgery. The mean operating time was longer for LP (161 ± 43 min) than that for OP (109 ± 32 min, p < 0.001). However, the mean operating time was not longer in the patient group receiving LP at ≤6 weeks (145 ± 21.6) compared to that in our main cohort receiving LP. There was no significant difference in the length of stay between the groups. Four patients after LP required emergency nephrostomy compared to one patient after OP. The rate of revision pyeloplasty in our main cohort aged 0-6 months at surgery was 8% in the patient group receiving LP and 14% in the patient group receiving OP (not significant). Three revisions after LP were due to persistent UPJO, and one was due to stent migration. Only one patient requiring revision pyeloplasty was less than 6 weeks old. Conclusion To our knowledge, this is one of the largest collectives of laparoscopic pyeloplasty performed in infants, and it is the youngest cohort published to date. Based on our experience, LP in neonates and infants under 6 months appears to be as effective as open surgery.
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Affiliation(s)
- S. Langreen
- Pediatric Surgery Clinic, Center for Pediatrics and Adolescent Medicine, Hannover Medical School, Hanover, Germany
| | - B. Ludwikowski
- Department of Pediatric Surgery, Kinder- und Jugendkrankenhaus AUF DER BULT, Hanover, Germany
| | - J. Dingemann
- Pediatric Surgery Clinic, Center for Pediatrics and Adolescent Medicine, Hannover Medical School, Hanover, Germany
| | - B. M. Ure
- Pediatric Surgery Clinic, Center for Pediatrics and Adolescent Medicine, Hannover Medical School, Hanover, Germany
| | - A. D. Hofmann
- Pediatric Surgery Clinic, Center for Pediatrics and Adolescent Medicine, Hannover Medical School, Hanover, Germany
| | - J. F. Kuebler
- Pediatric Surgery Clinic, Center for Pediatrics and Adolescent Medicine, Hannover Medical School, Hanover, Germany
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Scoville SD, Bergus K, Diefenbach KA, Dajusta DG, Fuchs ME, Michalsky MP, Aldrink JH. Robotic-Assisted Surgery in Patients Less than 15 kg: A Single Center Review. J Laparoendosc Adv Surg Tech A 2024; 34:434-437. [PMID: 38294893 DOI: 10.1089/lap.2023.0178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024] Open
Abstract
Introduction: Robotic-assisted surgery (RAS) is an increasingly utilized tool in children. However, utilization of RAS among infants and small children has not been well established. The purpose of this study was to review and characterize RAS procedures for children ≤15 kg. Methods: We performed a single institution retrospective descriptive analysis including all patients ≤15 kg undergoing RAS between January 2013 and July 2021. Data collection included procedure type, age, weight, gender, and surgical complications. Cases were further categorized according to surgical specialty: pediatric urology (PU), pediatric surgery (PS), and multiple specialties (MS). t-Tests were used for statistical analyses. Results: Since 2013, a total of 976 RAS were identified: 492 (50.4%) were performed by PU, 466 (47.8%) by PS, and 18 (1.8%) by MS. One hundred eighteen (12.1%) were performed on children ≤15 kg, consisting of 110 (93.2%) PU cases, 6 (5.1%) PS cases, and 2 (1.7%) MS cases. Procedures were significantly more common in the PU subgroup, mean of 12 cases/year, compared to PS subgroup, mean of 0.63 cases/year, (P < .01). The mean weight of PU patients (10.5 kg) was significantly less than PS patients (13.9 kg) (P < .01). Mean age was also significantly lower among PU patients (18.6 months) compared to PS (34.2 months) (P < .01). Conclusion: RAS among patients ≤15 kg is safe and feasible across pediatric surgical subspecialties. RAS was performed significantly more frequently by pediatric urologists in younger and smaller patients compared to pediatric surgeons. Further refinement of robotic technology and instrumentation should enhance the applicability of these procedures in this young group.
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Affiliation(s)
- Steven D Scoville
- Department of Surgery, Ohio State Wexner Medical Center, Columbus, Ohio, USA
- Divisions of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Katherine Bergus
- Department of Surgery, Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Karen A Diefenbach
- Department of Surgery, Ohio State Wexner Medical Center, Columbus, Ohio, USA
- Divisions of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Daniel G Dajusta
- Divisions of Urology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Molly E Fuchs
- Divisions of Urology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Marc P Michalsky
- Department of Surgery, Ohio State Wexner Medical Center, Columbus, Ohio, USA
- Divisions of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jennifer H Aldrink
- Department of Surgery, Ohio State Wexner Medical Center, Columbus, Ohio, USA
- Divisions of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
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Abdulfattah S, Mittal S. Pediatric Robot-Assisted Laparoscopic Pyeloplasty: Where Are We Now? Curr Urol Rep 2024; 25:55-61. [PMID: 38324220 DOI: 10.1007/s11934-024-01195-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/08/2024]
Abstract
PURPOSE OF REVIEW This review aims to provide an in-depth exploration of the recent advancements in robot-assisted laparoscopic pyeloplasty (RALP) and its evolving landscape in the context of infant pyeloplasty, complex genitourinary (GU) anatomy, recurrent ureteropelvic junction (UPJ) obstruction, cost considerations, and the learning curve. RECENT FINDINGS Recent literature highlights the safety and efficacy of RALP in treating the infant population, patients with complex GU anomalies, and recurrent UPJO which were all traditionally managed using the open approach. Cost considerations are evolving, with the potential for RALP to have a lesser financial burden. In addition, the learning curve for RALP is diminishing due to robust training programs and advances in research. RALP has become the gold standard in the treatment of UPJO in pediatric urology at many children's hospitals. Surgeon comfort and research in this space allow safe and successful reconstruction in the most challenging of cases.
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Affiliation(s)
- Suhaib Abdulfattah
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sameer Mittal
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Surgery/Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Chertin L, Lask A, Shumaker A, Zisman A, Neheman A. Repositioning of Ureteropelvic Junction in Robot-assisted Laparoscopic Pyeloplasty. Urology 2024; 184:195-198. [PMID: 37923088 DOI: 10.1016/j.urology.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/16/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To describe the technique of ureteropelvic junction (UPJ) repositioning in robot-assisted dismembered pyeloplasty as a modified approach during which the UPJ is brought to a new location to facilitate the anastomosis. MATERIALS AND METHODS Retrospective review of pediatric and adult cases of robot-assisted laparoscopic pyeloplasty performed between the years 2016 and 2022. In a select group of patients, repositioning of the UPJ was performed. Demographic data, surgical and post-surgical outcomes were compared to a group that underwent classical Anderson-Hynes (AH) dismembered pyeloplasty. RESULTS Overall, 70 patients underwent robot-assisted laparoscopic dismembered pyeloplasty and were included in the study, with 15 in the repositioning group and 55 in the AH group. The median age of patients included was 26 months (interquartile range (IQR) 7-203). Median operative time was 140 minutes (IQR 129-192) and 170 minutes (IQR 135-207) for the repositioning and AH group, respectively. The indications for UPJ repositioning were high UPJ insertion (n = 8), crossing vessel (n = 5), and renal malformations (n = 2). Clinical significance was shown in the Society of Fetal Urology classification and split renal function postoperatively, respectively (P <.001; P <.01). Postoperatively, both groups showed improvement in anterior posterior diameter (APD) and diuretic T1/2 (P = 0.48). There was 1 case of surgical failure requiring revisional surgery in the repositioning group (6.6%) and 3 in the AH group (5.5%) (P >.05). Overall, there were 3 cases of Clavien-Dindo Grade 3 complications, all in the AH group (2 cases of urine leak from anastomosis, 1 case of port side hernia). CONCLUSION Repositioning of the UPJ is optional in cases when the obstructed UPJ is in a suboptimal anatomical position.
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Affiliation(s)
- Leon Chertin
- Department of Urology, Shamir Medical Center, Zerifin, Israel; Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Avigal Lask
- Department of Urology, Shamir Medical Center, Zerifin, Israel; Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Andrew Shumaker
- Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Urology, Meir Medical Center, Kfar Saba, Israel
| | - Amnon Zisman
- Department of Urology, Shamir Medical Center, Zerifin, Israel; Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amos Neheman
- Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Urology, Meir Medical Center, Kfar Saba, Israel
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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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Cai PY, Lee RS. Ureteropelvic Junction Obstruction/Hydronephrosis. Urol Clin North Am 2023; 50:361-369. [PMID: 37385700 DOI: 10.1016/j.ucl.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Congenital hydronephrosis can be classified and managed based on the Urinary Tract Dilation consensus scoring system. Ureteropelvic junction obstruction is one of the most common causes of hydronephrosis in the pediatric population. Although most cases can be managed conservatively with follow-up and serial imaging, some patients need surgical repair because of renal function deterioration, infections, or symptoms. Additional research to create predictive algorithms or develop noninvasive biomarkers for renal deterioration is necessary to better identify surgical candidates. The robotic-assisted approach for pyeloplasty is becoming increasingly widespread and associated with shorter hospital stay, high success rates, and low complication rates.
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Affiliation(s)
- Peter Y Cai
- Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Hunnewell 390, Boston, MA 02115, USA
| | - Richard S Lee
- Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Hunnewell 390, Boston, MA 02115, USA; Department of Surgery, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
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Esposito C, Cerulo M, Lepore B, Coppola V, D'Auria D, Esposito G, Carulli R, Del Conte F, Escolino M. Robotic-assisted pyeloplasty in children: a systematic review of the literature. J Robot Surg 2023:10.1007/s11701-023-01559-1. [PMID: 36913057 PMCID: PMC10374693 DOI: 10.1007/s11701-023-01559-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/01/2023] [Indexed: 03/14/2023]
Abstract
Robotic pyeloplasty has become a natural progression from the development of open, then laparoscopic procedures to treat pediatric patients with ureteropelvic junction obstruction (UPJO). Robotic-assisted pyeloplasty (RALP) is now considered a new gold standard in pediatric MIS. A systematic review of the literature retrieved from PubMed and published in the last 10 years (2012-2022) was performed. This review underlines that in all children except the smallest infants, where the open procedure has benefits in terms of duration of general anesthetic and there are limitations in the size of instruments, robotic pyeloplasty is becoming the preferred procedure to perform in patients with UPJO. Results for the robotic approach are extremely promising, with shorter operative times than laparoscopy and equal success rates, length of stay and complications. In case of redo pyeloplasty, RALP is easier to perform than other open or MIS procedures. By 2009, robotic surgery became the most used modality to treat all UPJO and continues to grow in popularity. Robot-assisted laparoscopic pyeloplasty in children is safe and effective with excellent outcomes, even in redo pyeloplasty or challenging anatomical cases. Moreover, robotic approach shortens the learning curve for junior surgeons, who can readily achieve levels of expertise comparable to senior practitioners. However, there are still concerns regarding the cost associated with this procedure. Further high-quality prospective observational studies and clinical trials, as well as new technologies specific for the pediatric population, are advisable for RALP to reach the level of gold standard.
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Affiliation(s)
- Ciro Esposito
- Department of Translational Medical Sciences (DISMET), Pediatric Surgery Unit, "Federico II" University of Naples School of Medicine, Via S. Pansini 5, 80131, Naples, Italy.
| | - Mariapina Cerulo
- Department of Translational Medical Sciences (DISMET), Pediatric Surgery Unit, "Federico II" University of Naples School of Medicine, Via S. Pansini 5, 80131, Naples, Italy
| | - Benedetta Lepore
- Department of Translational Medical Sciences (DISMET), Pediatric Surgery Unit, "Federico II" University of Naples School of Medicine, Via S. Pansini 5, 80131, Naples, Italy
| | - Vincenzo Coppola
- Department of Translational Medical Sciences (DISMET), Pediatric Surgery Unit, "Federico II" University of Naples School of Medicine, Via S. Pansini 5, 80131, Naples, Italy
| | - Daniela D'Auria
- Faculty of Computer Science, Free University of Bolzano, Bolzano, Italy
| | - Giorgia Esposito
- Internal Medicine Unit, University of Naples "Federico II", Naples, Italy
| | - Roberto Carulli
- Department of Translational Medical Sciences (DISMET), Pediatric Surgery Unit, "Federico II" University of Naples School of Medicine, Via S. Pansini 5, 80131, Naples, Italy
| | - Fulvia Del Conte
- Department of Translational Medical Sciences (DISMET), Pediatric Surgery Unit, "Federico II" University of Naples School of Medicine, Via S. Pansini 5, 80131, Naples, Italy
| | - Maria Escolino
- Department of Translational Medical Sciences (DISMET), Pediatric Surgery Unit, "Federico II" University of Naples School of Medicine, Via S. Pansini 5, 80131, Naples, Italy
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Lombardo AM, Gundeti MS. Review of robot-assisted laparoscopic surgery in management of infant congenital urology: Advances and limitations in utilization and learning. Int J Urol 2023; 30:250-257. [PMID: 36520939 DOI: 10.1111/iju.15105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 11/14/2022] [Indexed: 12/23/2022]
Abstract
As robotic-assisted (RAL) surgery expanded to treat pediatric congenital disease, infant anatomy and physiology posed unique challenges that prompted adaptations to the technology and surgical technique, which are compiled and reviewed in this manuscript. From the beginning, collaboration with anesthesia is critical for a safe, efficient case including placement of an endotracheal tube rather than a laryngeal mask (LMA) and placement of a nasogastric tube and/or rectal tube to relieve distended stomach or bowel, respectively. Furthermore, end-tidal CO2 (EtCO2 ) is important for monitoring and predicting the effects of pneumoperitoneum on caridiovascular physiology, incranial pressure, and risk of acidosis and hypercarbia. Positioning can further exacerbate these effects and affect intra-abdominal working space. For infant robotic pyeloplasty and heminephrectomy, a "beanbag" is commonly used for stabilization in the lateral decubitus position. We advise against the use of a "baby bump" because it brings the bowels and vasculature more anterior than expected. Pnuemoperitoneum pressure of 8-10 mmHg during port placement maximizes safety, but thereafter, the pneumoperitoneum pressure can be minimized to 6-8 mmHg during the procedure without compromising the visual field. Port sites should be marked after insufflation, followed by the open Hasson technique for peritoneal access and port placement under direct vision with intussusception of the trocars to avoid vascular or bowel injury. Additional tips can be obtained through this manuscript, immersive fellowships, and mini-fellowships. Ulitmately, infant robotic surgery has the potential to benefit many children but is presently limited by the lack of pediatric-specific robotic technology and its associated costs.
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Affiliation(s)
- Alyssa M Lombardo
- The University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Mohan S Gundeti
- The University of Chicago Comer Children's Hospital, Chicago, Illinois, USA
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Jacobson JC, Pandya SR. Pediatric robotic surgery: An overview. Semin Pediatr Surg 2023; 32:151255. [PMID: 36736161 DOI: 10.1016/j.sempedsurg.2023.151255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Pediatric robotic surgery offers children a minimally invasive approach with numerous advantages over open or thoracoscopic and laparoscopic surgery. However, despite its widespread adoption for adult patients, the utilization of robotic surgery within pediatrics has been relatively slower to progress. This paper provides an overview of pediatric robotic surgery and discusses benefits, limitations, and strategies for successful implementation of robotics within pediatric surgical practice.
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Affiliation(s)
- Jillian C Jacobson
- Division of Pediatric Surgery, Children's Medical Center & Department of Surgery, University of Texas Southwestern Medical Center, 1935 Medical District Drive, Suite D2000, Dallas, TX 75235, USA
| | - Samir R Pandya
- Division of Pediatric Surgery, Children's Medical Center & Department of Surgery, University of Texas Southwestern Medical Center, 1935 Medical District Drive, Suite D2000, Dallas, TX 75235, USA.
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10
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Robotically Assisted Surgery in Children—A Perspective. CHILDREN 2022; 9:children9060839. [PMID: 35740776 PMCID: PMC9221697 DOI: 10.3390/children9060839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 05/16/2022] [Accepted: 06/03/2022] [Indexed: 11/26/2022]
Abstract
The introduction of robotically assisted surgery was a milestone for minimally invasive surgery in the 21st century. Currently, there are two CE-approved robotically assisted surgery systems for use and development in pediatrics. Specifically, tremor filtration and optimal visualization are approaches which can have enormous benefits for procedures in small bodies. Robotically assisted surgery in children might have advantages compared to laparoscopic or open approaches. This review focuses on the research literature regarding robotically assisted surgery that has been published within the past decade. A literature search was conducted to identify studies comparing robotically assisted surgery with laparoscopic and open approaches. While reported applications in urology were the most cited, three other fields (gynecology, general surgery, and “others”) were also identified. In total, 36 of the publications reviewed suggested that robotically assisted surgery was a good alternative for pediatric procedures. After several years of experience of this surgery, a strong learning curve was evident in the literature. However, some authors have highlighted limitations, such as high cost and a limited spectrum of small-sized instruments. The recent introduction of reusable 3 mm instruments to the market might help to overcome these limitations. In the future, it can be anticipated that there will be a broader range of applications for robotically assisted surgery in selected pediatric surgeries, especially as surgical skills continue to improve and further system innovations emerge.
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11
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Ordóñez J, Ortiz R, Parente A, Burgos L, Fernández-Bautista B, Pérez-Egido L, Angulo JM. Long Term Outcome of 112 Pediatric Patients With Ureteroplevic Junction Obstruction Treated by Endourologic Retrograde Balloon Dilatation. Front Pediatr 2022; 10:863625. [PMID: 35547531 PMCID: PMC9084922 DOI: 10.3389/fped.2022.863625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To analyze the effectiveness, complications and long-term outcome of the patients with ureteropelvic junction obstruction (UPJO) treated by endoscopic retrograde balloon dilatation (ERBD) in the largest series reported. MATERIALS AND METHODS Between years 2004 and 2018, 112 patients with primary unilateral UPJO were treated by ERBD. Endoscopic treatment consisted on a retrograde balloon dilatation of the ureteropelvic junction (UPJ), through cystoscopy and under fluoroscopic guidance, using high-pressure balloon catheters. In case of persistence in the balloon notch, a Cutting Balloon™ catheter was used. Double-J stent was placed after dilatation. RESULTS Mean age at surgery was 13.1 ± 21.3 months, 92 cases being younger than 18 months. Mean operative time was 24.4 ± 10.3 min; hospital stay was 1 day in 82% of patients. No intraoperative complications occurred. UPJ was calibrated at time of stent removal with cystoscopy 39.1 ± 13.7 days after dilatation. ERBD was not possible in 11 cases. An additional procedure was needed in 24 cases: second ERBD (n = 11, seven during the stent withdrawal), a third dilatation (n = 3) due to persistent hydronephrosis, and percutaneous endopyelotomy (n = 3) or open pyeloplasty (n = 7) in cases of technical failure. Significant improvement in postoperative ultrasound measures were observed (p < 0.05, T-test). Long-term success rate was 76.8% after one dilatation, and 86.6% in those who required up to 2 dilatations. Mean follow-up was 66.7 ± 37.5 months. CONCLUSIONS ERBD is a feasible and safe option for the minimally invasive treatment of UPJ obstruction in infants. Long-term outcome is acceptable with a very low complication rate.
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Affiliation(s)
- Javier Ordóñez
- Pediatric Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rubén Ortiz
- Pediatric Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Laura Burgos
- Pediatric Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Laura Pérez-Egido
- Pediatric Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - José María Angulo
- Pediatric Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Beale R, Sicilila S, Riestra P, Albala DM. Are robots the future? A case for robotic pyeloplasty as the gold standard treatment in ureteropelvic junction obstruction. Curr Opin Urol 2022; 32:109-115. [PMID: 34798638 DOI: 10.1097/mou.0000000000000944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Robotic pyeloplasty is still a relatively novel procedure. Clinically, early studies have shown high success rates, decreased complication rates, decreased length of hospital stay, and better cosmetic results. This goal of this article is to argue for the use of robotic pyeloplasty as the gold standard of ureteropelvic junction obstruction (UPJO) treatment. Results of studies that have compared robotic pyeloplasty with other procedures currently used are reviewed. RECENT FINDINGS Our study, a comprehensive review of published outcomes of robotic pyeloplasty and alternative therapies, consisted of 666 pediatric patients and 653 adult patients. Our review coincided with the previously established studies that robotic pyeloplasty shows equivalent surgical success rates as previous standard of care treatments. Open pyeloplasty has fallen out of favor as standard of care due to the increased length of hospital stay, increased adverse events, and the undesirable aesthetics. SUMMARY The use of robotic pyeloplasty has shown to have clinical outcomes that are consistent with other intervention for UPJO, with a potential decrease in length of stay and morbidity. More work has to be done to develop ways to decrease cost of the robot to help establish it as the gold standard for UPJO treatment.
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Affiliation(s)
- Robert Beale
- SUNY Downstate Health Sciences University, New York
| | | | - Paola Riestra
- Associated Medical Professionals, Syracuse, New York, USA
| | - David M Albala
- SUNY Downstate Health Sciences University, New York
- Associated Medical Professionals, Syracuse, New York, USA
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13
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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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Greenwald DT, Mohanty A, Andolfi C, Gundeti M. Systematic Review and Meta-Analysis of Pediatric Robotic Assisted Laparoscopic Pyeloplasty (RALP). J Endourol 2021; 36:448-461. [PMID: 34806401 DOI: 10.1089/end.2021.0363] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION To perform a systematic review and meta-analysis of outcomes of robotic-assisted laparoscopic pyeloplasty for UPJ obstruction in children. EVIDENCE ACQUISITION A systematic review of the English-language literature on surgical techniques and perioperative outcomes of robotic-assisted laparoscopic pyeloplasty for UPJ obstruction in children was performed without time filters using the MEDLINE (via PubMed), EMBASE, and Cochrane databases in July 2020 according to the PRISMA statement recommendations. EVIDENCE SYNTHESIS Overall, 58 studies were selected for qualitative analysis, 46 of which were included in the meta-analysis. Nearly all studies included were observational and retrospective, either cohort or case-control. The quality of evidence was assessed using Modified Newcastle Ottawa Scoring, with the majority of studies scoring medium or high quality. The mean success rate was 95.4% (CI 91.0-99.3%), over a wide age range. There was a noticeable heterogeneity in reported follow up length and definitions of success rate. The majority of studies reported length of stay of ~1 day. The mean overall complication rate was 12%. For studies that reported complication rate by grade, the mean low Clavien grade (grade 2 or less) complication rate was 9.3% and the mean high Clavien grade (grade 3 or more) complication rate was 6.5%. CONCLUSIONS Robotic assisted surgery is technically feasible and has been shown to achieve very favorable outcomes for pyeloplasty in children. The evidence however is mostly retrospective and from single sites, which introduces potential biases. Further research is needed to further elucidate RALP benefits compared to the open and laparoscopic approach. As a RCT may not be practical in this space, perhaps a prospective multi-institutional design with a uniform reporting system of pediatric RALP is the next step to define its benefits and limits.
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Affiliation(s)
- David Theodore Greenwald
- The University of Chicago Hospital, 21727, 5841 S. Maryland Ave, Chicago, Illinois, United States, 60637-1470;
| | - Amrita Mohanty
- The University of Chicago Hospital, 21727, Chicago, Illinois, United States;
| | - Ciro Andolfi
- The University of Chicago Medical Center, 21727, Surgery (Urology), Chicago, Illinois, United States;
| | - Mohan Gundeti
- University of Chicago , Surgery( Urology), 5841, South Maryland Av, chicago, chicago , Illinois, United States, 60637;
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15
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Navarrete-Arellano M. Robotic-Assisted Minimally Invasive Surgery in Children. LATEST DEVELOPMENTS IN MEDICAL ROBOTICS SYSTEMS 2021. [DOI: 10.5772/intechopen.96684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Currently, minimally invasive surgery (MIS) includes conventional laparo-thoracoscopic surgery and robot-assisted surgery (RAS) or robotic surgery. Robotic surgery is performed with robotic devices, for example the Da Vinci system from Intuitive Surgical, which has a miniaturized camera capable of image magnification, a three-dimensional image of the surgical field, and the instruments are articulated with 7 degrees of freedom of movement, and the surgeon operates in a sitting position at a surgical console near the patient. Robotic surgery has gained an enormous surge in use on adults, but it has been slowly accepted for children, although it offers important advantages in complex surgeries. The areas of application of robotic surgery in the pediatric population include urological, general surgery, thoracic, oncological, and otorhinolaryngology, the largest application has been in urological surgery. There is evidence that robotic surgery in children is safe and it is important to offer its benefits. Intraoperative complications are rare, and the frequency of postoperative complications ranges from 0–15%. Recommendations for the implementation of a pediatric robotic surgery program are included. The future will be fascinating with upcoming advancements in robotic surgical systems, the use of artificial intelligence, and digital surgery.
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Chandrasekharam VVS, Babu R. A systematic review and meta-analysis of conventional laparoscopic versus robot-assisted laparoscopic pyeloplasty in infants. J Pediatr Urol 2021; 17:502-510. [PMID: 33812779 DOI: 10.1016/j.jpurol.2021.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 03/11/2021] [Accepted: 03/11/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVE While there are several reports confirming the safety and efficacy of laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP) in children there have been none comparing LP and RALP specifically in infants. In this meta-analysis, we have compared the outcomes of LP and RALP in infants. METHODS Pubmed (Medline), Publon, Index Medicus and Embase were searched using the search terms: pyeloplasty (laparoscopic OR robot-assisted) AND (infant), to identify all papers pertaining to LP and RALP. Systematic review was performed to identify information regarding number of patients/renal units, age, body weight, operating time, hospital stay, success and complications. Meta-analysis of heterogeneity was reported with I2statistics. Once heterogeneity was found low, the pooled outcomes were compared with student's t test and Fishers exact test, wherever appropriate. RESULTS After screening a total of 267 articles, 18 articles were included (10 articles on LP, 7 on RALP, 1 reporting both), comprising 323 renal units for LP and 173 renal units for RALP. With low heterogeneity (I2: 0%) both groups were considered to have been conducted under similar conditions for fixed effect model. There was no significant difference between the success rates of LP or RALP (97.5% vs 94.8%; p = 0.21). The mean age at operation was significantly lower for LP (5.6 ± 1.8 months) than RALP (7.2 ± 1.2 months, P = 0.0001). The duration of surgery was 137 ± 45 min for LP while significantly higher at 179 ± 49 min for RALP (p = 0.0001). The mean (s.d) time to discharge was 2.0 (1.9) days for LP while 1.3 (0.4) days for RALP. The overall complication rate was significantly higher (summary table) for RALP than LP (p = 0.03), mainly due to more port-site hernias in RALP. DISCUSSION In the present study, we found that the success of LP and RALP in infants was similar. RALP in infants had longer duration of surgery, similar hospital stay and higher Clavien-3 complications than LP. While several studies have reported favorable outcomes for RALP over LP in children, this was not the case in infants. The smaller workspace, in an infant, can significantly limit the mobility of robotic instruments and increase the chance of port-site conflicts or trocar collisions. The use of larger robotic ports and instruments in the small space of infant abdomen might have been responsible for higher complications in RALP, including significantly larger number of port-site hernias. This meta-analysis represents the early experience of most RALP in infants, and it is possible that with experience RALP outcomes in infants also will catch up with LP. Miniaturization of robotic instruments might render RALP the future standard of care for pyeloplasty in infants.
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Affiliation(s)
- V V S Chandrasekharam
- Pediatric Surgery, Pediatric Urology and MAS, Ankura Hospitals for Women and Children, Hyderabad, Telangana, India.
| | - Ramesh Babu
- Pediatric Urology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
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17
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Kang SK, Jang WS, Kim SH, Kim SW, Han SW, Lee YS. Comparison of intraoperative and short-term postoperative outcomes between robot-assisted laparoscopic multi-port pyeloplasty using the da Vinci Si system and single-port pyeloplasty using the da Vinci SP system in children. Investig Clin Urol 2021; 62:592-599. [PMID: 34387035 PMCID: PMC8421989 DOI: 10.4111/icu.20200569] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/07/2021] [Accepted: 04/19/2021] [Indexed: 11/18/2022] Open
Abstract
PURPOSE We compared the intraoperative and postoperative outcomes of single-port robot-assisted laparoscopic pyeloplasty (S-RALP) using the da Vinci SP® system and conventional multi-port robot-assisted laparoscopic pyeloplasty (M-RALP) in pediatric patients. MATERIALS AND METHODS Multi-port and single-port pyeloplasty have been performed in pediatric patients in our institution since October 2015 and February 2019, respectively. We conducted an entire cohort comparison. Considering the learning curve of M-RALP, we defined the last 15 cases of M-RALP as a subgroup of M-RALP and compared this subgroup with the entire cohort of S-RALP patients. RESULTS Thirty-one patients who underwent multi-port pyeloplasty and 15 patients who underwent single-port pyeloplasty were enrolled in this study. Age, height, body weight, laterality, surgical indication, and ipsilateral differential renal function were statistically similar in the M-RALP and S-RALP groups. The median operative time (3.0 h vs. 2.4 h; p=0.01) and the median console time (2.2 h vs. 1.5 h; p<0.001) were longer in the M-RALP group than in the S-RALP group. There was no significant difference in operative time or console time between the M-RALP subgroup and the S-RALP group. There were no significant differences in the length of hospitalization, pain score, morphine-equivalent use of analgesics, or postoperative differential renal function in all comparisons. CONCLUSIONS This study confirmed that pyeloplasty using the da Vinci® SP system can be started by robotic surgeons who can overcome the learning curve. Robot-assisted laparoscopic single-port pyeloplasty is feasible in noninfant pediatric patients.
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Affiliation(s)
- Sung Ku Kang
- Department of Urology, Yonsei University College of Medicine, Seoul, Korea.,Department of Urology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Won Sik Jang
- Department of Urology, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Hoon Kim
- Department of Pediatric Urology, Severance Children's Hospital, Yonsei University Health System, Seoul, Korea
| | - Sang Woon Kim
- Department of Urology, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Won Han
- Department of Urology, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Seung Lee
- Department of Urology, Yonsei University College of Medicine, Seoul, Korea.
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18
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Infant Robot-assisted Laparoscopic Pyeloplasty: Outcomes at a Single Institution, and Tips for Safety and Success. Eur Urol 2021; 80:621-631. [PMID: 34247895 DOI: 10.1016/j.eururo.2021.06.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/24/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Since its first description, multiple reports proved efficacy and safety of the robotic platform. Further progress has been made allowing for the application of robotic surgery to smaller patients, including infants. Despite the early favorable results, the use of robot surgery in infants is still controversial and more studies are needed to confirm its benefits. OBJECTIVE To our knowledge, we present the largest single-institution case series of robot-assisted laparoscopic pyeloplasty (RAL-P) in infants, aiming to contribute to the current literature with a guide for key technical steps and safety tips for infant RAL-P. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective review of a prospectively maintained database. The study protocol was approved by the institutional review board. SURGICAL PROCEDURE Only infants (≤12 mo of age) with a diagnosis of congenital ureteropelvic junction obstruction (UPJO) undergoing primary robotic dismembered pyeloplasty were included in the study. MEASUREMENTS We critically reviewed the clinical outcomes, described the main steps of the operation, and shared tips for a safe approach. RESULTS AND LIMITATIONS From January 2012 to August 2019, 44 infants underwent RAL-P for UPJO--33 (75%) males and 11 (25%) females. All robotic cases were completed successfully, with no laparotomic conversions. The median age and weight were 4 (1-12) mo and 6.8 (3.8-10.5) kg, respectively. The mean operative time was 142 (±25) min. The mean estimated blood loss was 7 (±3.6) ml, and no intraoperative complications occurred. The mean length of hospital stay (LOS) was 1.4 (±0.7) d. Seven (15.6%) patients had postoperative complications-one (2%) ileus (Clavien-Dindo grade [CDG] I), four (9%) urinary tract infections (CDG II), and two (4.5%) port-site hernias (CDG III). At a median follow-up of 19 mo, the success rate was 100%. CONCLUSIONS Given the successful outcomes, benefits of decreased LOS, and improved cosmesis, RAL-P is an appealing management option for UPJO in infants. Market release of new systems, further miniaturization of instruments, and more affordable costs will hopefully be shedding light on more complex applications. PATIENT SUMMARY Infants (≤12 mo of age) diagnosed with ureteropelvic junction obstruction undergoing primary robotic dismembered pyeloplasty were selected and included in this study. No intraoperative complications or conversion to an open approach occurred. Seven patients (16%) developed postoperative complications-one (2%) postoperative ileus, four (9%) urinary tract infections, and two (4.5%) port-site hernias. At a median follow-up of 19 (7-66) mo, the success rate was 100%.
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19
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Artificial Intelligence and Its Impact on Urological Diseases and Management: A Comprehensive Review of the Literature. J Clin Med 2021; 10:jcm10091864. [PMID: 33925767 PMCID: PMC8123407 DOI: 10.3390/jcm10091864] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/04/2021] [Accepted: 04/08/2021] [Indexed: 12/22/2022] Open
Abstract
Recent advances in artificial intelligence (AI) have certainly had a significant impact on the healthcare industry. In urology, AI has been widely adopted to deal with numerous disorders, irrespective of their severity, extending from conditions such as benign prostate hyperplasia to critical illnesses such as urothelial and prostate cancer. In this article, we aim to discuss how algorithms and techniques of artificial intelligence are equipped in the field of urology to detect, treat, and estimate the outcomes of urological diseases. Furthermore, we explain the advantages that come from using AI over any existing traditional methods.
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20
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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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21
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Li P, Zhou H, Cao H, Guo T, Zhu W, Zhao Y, Tao T, Zhou X, Ma L, Yang Y, Feng Z. Early Robotic-Assisted Laparoscopic Pyeloplasty for Infants Under 3 Months With Severe Ureteropelvic Junction Obstruction. Front Pediatr 2021; 9:590865. [PMID: 33777859 PMCID: PMC7987794 DOI: 10.3389/fped.2021.590865] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 02/04/2021] [Indexed: 12/14/2022] Open
Abstract
Objective: To present our primary experience of robotic-assisted laparoscopic pyeloplasty (RALP) for severe ureteropelvis junction obstruction (UPJO) infants under 3 months. Methods: We performed a retrospective study of 9 infants under 3 months who underwent RALP for severe UPJO between April 2017 and March 2019 in our center. The severe UPJO was defined as infants with severe hydronephrosis (Society of Fetal Urology grades III or IV, anteroposterior diameter >3 cm or split renal function <40% or T 1/2 >20 min) involving bilateral, solitary kidney, or contralateral renal hypoplasia UPJO at the same time. All clinical, perioperative, and postoperative information was collected. Results: There were four bilateral UPJO cases, two solitary kidney UPJO cases and three unilateral UPJO with contralateral renal hypoplasia cases included. One single surgeon performed RALP on all of the infants. The mean age of the infants was 1.62 ± 0.54 months. The mean operative time was 109.55 ± 10.47 min. The mean estimated blood loss was 19.29 ± 3.19 ml, and the mean length of hospital stay was 5.57 ± 0.73 days. According to the ultrasonography results, all patients had a significant recovery of renal function at 12 months after the operation. Conclusions: To maximize the protection of renal function, early RALP is a safe and feasible option for the treatment of severe UPJO in infants under 3 months.
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Affiliation(s)
- Pin Li
- Department of Pediatric Urology, Bayi Children's Hospital, Affiliated of the Seventh Medical Center of People's Liberation Army General Hospital, Beijing, China
| | - Huixia Zhou
- Department of Pediatric Urology, Bayi Children's Hospital, Affiliated of the Seventh Medical Center of People's Liberation Army General Hospital, Beijing, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Hualin Cao
- Department of Pediatric Urology, Bayi Children's Hospital, Affiliated of the Seventh Medical Center of People's Liberation Army General Hospital, Beijing, China.,Department of Urology, Nan Xi Shan Hospital of Guangxi Zhuang Autonomous Region, Guilin, China
| | - Tao Guo
- Medical School of Chinese People's Liberation Army, Beijing, China
| | - Weiwei Zhu
- Medical School of Chinese People's Liberation Army, Beijing, China
| | - Yang Zhao
- Medical School of Chinese People's Liberation Army, Beijing, China.,Department of Pediatrics, The Third Medical Center of People's Liberation Army General Hospital, Beijing, China
| | - Tian Tao
- Department of Pediatric Urology, Bayi Children's Hospital, Affiliated of the Seventh Medical Center of People's Liberation Army General Hospital, Beijing, China
| | - Xiaoguang Zhou
- Department of Pediatric Urology, Bayi Children's Hospital, Affiliated of the Seventh Medical Center of People's Liberation Army General Hospital, Beijing, China
| | - Lifei Ma
- Department of Pediatric Urology, Bayi Children's Hospital, Affiliated of the Seventh Medical Center of People's Liberation Army General Hospital, Beijing, China
| | - Yunjie Yang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Department of Urology, The Affiliated Nanhai Hospital of the Southern Medical University, Foshan, China
| | - Zhichun Feng
- Department of Pediatric Urology, Bayi Children's Hospital, Affiliated of the Seventh Medical Center of People's Liberation Army General Hospital, Beijing, China
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22
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Wong YS, Pang KKY, Tam YH. Comparing Robot-Assisted Laparoscopic Pyeloplasty vs. Laparoscopic Pyeloplasty in Infants Aged 12 Months or Less. Front Pediatr 2021; 9:647139. [PMID: 34195160 PMCID: PMC8236621 DOI: 10.3389/fped.2021.647139] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/21/2021] [Indexed: 01/08/2023] Open
Abstract
Objective: To investigate the outcomes of minimally invasive approach to infants with ureteropelvic junction (UPJ) obstruction by comparing the two surgical modalities of robot-assisted laparoscopic pyeloplasty (RALP) and laparoscopic pyeloplasty (LP). Methods: We conducted a retrospective review of all consecutive infants aged ≤12 months who underwent either LP or RALP in a single institution over the period of 2008-Jul 2020. We included primary pyeloplasty cases that were performed by or under the supervision of the same surgeon. Results: Forty-six infants (LP = 22; RALP = 24) were included with medians of age and body weight at 6 months (2-12months) and 8.0 kg (5.4-10 kg), respectively. There was no difference between the two groups in the patients' demographics and pre-operative characteristics. All infants underwent LP or RALP successfully without conversion to open surgery. None had intraoperative complications. Operative time (OT) was 242 min (SD = 59) in LP, compared with 225 min (SD = 39) of RALP (p = 0.25). Linear regression analysis showed a significant trend of decrease in OT with increasing case experience of RALP(p = 0.005). No difference was noted in the post-operative analgesic requirement. RALP was associated with a shorter hospital length of stay than LP (3 vs. 3.8 days; p = 0.009). 4/22(18%) LP and 3/24(13%) RALP developed post-operative complications (p = 0.59), mostly minor and stent-related. The success rates were 20/22 (91%) in LP and 23/24 (96%) in RALP (p = 0.49). Conclusions: Pyeloplasty by minimally invasive approach is safe and effective in the infant population. RALP may have superiority over LP in infants with its faster recovery and a more manageable learning curve to acquire the skills.
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Affiliation(s)
- Yuenshan Sammi Wong
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kristine Kit Yi Pang
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Yuk Him Tam
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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Masieri L, Sforza S, Grosso AA, Valastro F, Tellini R, Cini C, Landi L, Taverna M, Elia A, Mantovani A, Minervini A, Carini M. Robot-assisted laparoscopic pyeloplasty in children: a systematic review. MINERVA UROL NEFROL 2020; 72:673-690. [DOI: 10.23736/s0393-2249.20.03854-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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24
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Tiryaki S, Turna B, Kısmalı E, Ulman İ. Robotic partial nephrectomy in a child with kidney tumor. Turk J Urol 2020; 45:S188-S191. [PMID: 33120012 DOI: 10.5152/tud.2018.52028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 01/29/2018] [Indexed: 11/22/2022]
Abstract
Robotic surgery is gaining wider utility in adults; however, few reports have addressed the applicability of robotic surgery for renal tumors in children. The aim of this report is to share our experience in an 8-year-old child with metanephric stromal tumor. To our knowledge, besides being a rare tumor, this is the youngest case reported in the literature whose kidney tumor has been successfully removed with robotic partial nephrectomy. There is a worldwide tendency to perform minimal invasive surgery for kidney tumors. In the presence of an experienced team and proper conditions, we believe that robotic partial nephrectomy will be the preferred option in future.
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Affiliation(s)
- Sibel Tiryaki
- Department of Pediatric Surgery, Division of Pediatric Urology, Ege University School of Medicine, İzmir, Turkey
| | - Burak Turna
- Department of Urology, Ege University School of Medicine, İzmir, Turkey
| | - Erkan Kısmalı
- Department of Radiology, Ege University School of Medicine, İzmir, Turkey
| | - İbrahim Ulman
- Department of Pediatric Surgery, Division of Pediatric Urology, Ege University School of Medicine, İzmir, Turkey
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Leonardo CR, Muzzi A, Tavora JE, Soares RQ. The outcomes of mini-laparoscopic pyeloplasty in children - brazilian experience. Int Braz J Urol 2020; 46:253-259. [PMID: 32022515 PMCID: PMC7025835 DOI: 10.1590/s1677-5538.ibju.2019.0381] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/30/2019] [Indexed: 11/23/2022] Open
Abstract
Objetive Pelvicureteric junction (PUJ) obstruction is the main cause of hydronephrosis in childhood. Open pyeloplasty has been the gold standard treatment of this condition with success rate above 90%. The role of laparoscopic pyeloplasty (LP) in children is less well defined and has slowly emerged as an alternative procedure. We report outcomes of our initial experience with LP in 38 children from 2 months of age. Materials and Methods From June 2015 to December 2017 38 children aged 2-60 months (mean age 1.7 years) underwent LP for correction of PUJ obstruction. The mean pre operative anteroposterior diameter of the renal pelvis (APD) was 43,5mm and all patients had hydronephrosis (APD 21.4-76 mm) and obstructed curve on diuretic renogram. Anderson-Hynes pyeloplasty was the performed technique. Results are reported. Results Mean operative time was 107 minutes (70-180) with no conversion to open procedure. Pain control was needed mainly in the first 12hs. Mean hospitalization was 2 days (1-5). There were complications in 5 children not affecting the final outcome. Two patients had a re-obstruction requiring a second procedure with good result. The mean follow up was 18 months (13-36). The mean reduction on the postoperative APD was 41% - p<0,001 (end APD 5 to 41mm). Overall success rate was 94,7%. All children had good cosmetic results. Conclusions This is a small series limited by short follow up, however its data suggest that LP has good functional and cosmetic results, not compromising the success of the open procedure, regardless patient age.
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Affiliation(s)
- Cristiane Reis Leonardo
- Departamento de Urologia Pediátrica, Neocentro - Hospital Vila da Serra, Nova Lima, MG, Brasil
| | - Alexandra Muzzi
- Departamento de Cirurgia Pediátrica, Neocentro - Hospital Vila da Serra, Nova Lima, MG, Brasil
| | - José Eduardo Tavora
- Departamento de Urologia, Neocentro - Hospital Vila da Serra, Nova Lima, MG, Brasil
| | - Rodrigo Q Soares
- Departamento de Urologia, Neocentro - Hospital Vila da Serra, Nova Lima, MG, Brasil
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Esposito C, Masieri L, Castagnetti M, Pelizzo G, De Gennaro M, Lisi G, Cobellis G, Gamba P, Di Benedetto V, Escolino M. Current Status of Pediatric Robot-Assisted Surgery in Italy: Epidemiologic National Survey and Future Directions. J Laparoendosc Adv Surg Tech A 2020. [DOI: 10.1089/lap.2019.0516] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Ciro Esposito
- Pediatric Surgery Unit, Federico II University of Naples, Naples, Italy
| | - Lorenzo Masieri
- Pediatric Urology Unit, Meyer Children Hospital, Florence, Italy
| | | | - Gloria Pelizzo
- Pediatric Surgery Unit, Children's Hospital G. Di Cristina, ARNAS Civico-Di Cristina-Benfratelli, Palermo, Italy
| | - Mario De Gennaro
- Pediatric Urology Unit, Bambin Gesù Children Hospital, Rome, Italy
| | - Gabriele Lisi
- Pediatric Surgery Unit, G. D'Annunzio University of Chieti, Pescara, Italy
| | - Giovanni Cobellis
- Pediatric Surgery Unit, Azienda Ospedaliero-Universitaria, Ancona, Italy
| | | | | | - Maria Escolino
- Pediatric Surgery Unit, Federico II University of Naples, Naples, Italy
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Passoni NM, Peters CA. Managing Ureteropelvic Junction Obstruction in the Young Infant. Front Pediatr 2020; 8:242. [PMID: 32537441 PMCID: PMC7267033 DOI: 10.3389/fped.2020.00242] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/20/2020] [Indexed: 12/23/2022] Open
Abstract
In the last decade, management of congenital UPJ obstruction has become progressively observational despite the lack of precise predictors of outcome. While it is clear that many children will have resolution of their hydronephrosis and healthy kidneys, it is equally clear that there are those in whom renal functional development is at risk. Surgical intervention for the young infant, under 6 months, has become relatively infrequent, yet can be necessary and poses unique challenges. This review will address the clinical evaluation of UPJO in the very young infant and approaches to determining in whom surgical intervention may be preferable, as well as surgical considerations for the small infant. There are some clinical scenarios where the need for intervention is readily apparent, such as the solitary kidney or in child with infection. In others, a careful evaluation and discussion with the family must be undertaken to identify the most appropriate course of care. Further, while minimally invasive pyeloplasty has become commonly performed, it is often withheld from those under 6 months. This review will discuss the key elements of that practice and offer a perspective of where minimally invasive pyeloplasty is of value in the small infant. The modern pediatric urologist must be aware of the various possible clinical situations that may be present with UPJO and feel comfortable in their decision-making and surgical care. Simply delaying an intervention until a child is bigger may not always be the best approach.
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Barashi NS, Andolfi C, Wallace A, Rodriguez MV, Schadler E, Gundeti MS. Lessons learned from a single-surgeon series of paediatric robot-assisted laparoscopic urological procedures: predictors of high-grade postoperative complications. BJU Int 2019; 124:649-655. [PMID: 30933406 DOI: 10.1111/bju.14757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To describe postoperative complications after robot-assisted laparoscopic urological surgery in children, and identify potential predictors of these complications by analysing the outcomes of a large-volume single-surgeon experience. PATIENTS AND METHODS We reviewed our institutional database to identify all robot-assisted laparoscopy (RAL) cases performed between December 2007 and December 2017. Patients were grouped into three cohorts based on the anatomical location of the procedure: upper urinary tract (kidney and renal pelvis); lower urinary tract (ureter); and lower urinary tract reconstruction with bowel (bladder reconstruction). A descriptive analysis of baseline characteristics, intra-operative variables and postoperative outcomes was carried out. All complications were graded using the Clavien-Dindo scale, and grouped based on type and time of occurrence (<30, 30-90, >90 days). Multivariable logistic regression analysis was performed to identify predictors of high-grade complications (Clavien-Dindo grade ≥ III). We also measured complication rates based on year of surgery and surgical caseload. RESULTS Our database included a total of 326 patients, of whom 57% (n = 186) underwent upper urinary tract procedures, 30% (n = 97) ureteric procedures, and 13% bladder reconstruction. The median follow-up for each procedure was 13, 11 and 57 months, respectively. Of the total, 10 cases were converted to an open approach and excluded from further analysis. The most common types of complication in all groups were infections (urinary tract infections) and urinary complications (urine leaks and urolithiasis). Bladder reconstructive procedures, which require the use of bowel, presented the highest rate of high-grade complications (32%). Length of hospital stay (LOS; odds ratio [OR] 1.33, confidence interval [CI] 1.16-1.53), estimated blood loss (EBL) in surgery (OR 1.01, CI 1.002-1.019) and operating time (OR 1.004, CI 1.002-1.006) were all associated with increased odds of high-grade complications on multivariate analysis (P < 0.05). CONCLUSIONS In this single-surgeon series, we have described the most commonly encountered complications after RAL in paediatric urology, finding rates similar to the complication rates reported in the current literature on other surgical approaches. In addition, LOS, operating time and EBL, which are probable surrogates of case complexity, were associated with increased odds of high-grade complications.
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Affiliation(s)
- Nimrod S Barashi
- Department of Surgery, Section of Urology, The University of Chicago, Chicago, IL, USA
| | - Ciro Andolfi
- Department of Surgery, Section of Urology, The University of Chicago, Chicago, IL, USA
| | - Aaron Wallace
- Pritzker School of Medicine, The University of Chicago, Chicago, IL, USA
| | - Maria V Rodriguez
- Department of Surgery, Section of Urology, The University of Chicago, Chicago, IL, USA
| | - Eric Schadler
- Pritzker School of Medicine, The University of Chicago, Chicago, IL, USA
| | - Mohan S Gundeti
- Department of Surgery, Section of Urology, The University of Chicago, Chicago, IL, USA
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Robot-assisted laparoscopic pyeloplasty in infants and children: is it superior to conventional laparoscopy? World J Urol 2019; 38:1827-1833. [PMID: 31506749 DOI: 10.1007/s00345-019-02943-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 08/30/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Open pyeloplasty (OP) has been the first-line treatment for ureteropelvic junction obstruction (UPJO) since it was first described by Anderson and Hynes. The use of minimally invasive surgery (MIS) to treat UPJO in the pediatric population has increased in recent years, due to decreased morbidity and shorter recovery times. Recently, robot-assisted laparoscopic pyeloplasty (RALP) has seen a steady expansion. Unlike laparoscopic pyeloplasty (LP), RALP comes with a more manageable learning curve aided by specialized technological advantages such as high-resolution three-dimensional view, tremor filtration with motion scaling, and highly dexterous wrist-like instruments. With this review, we aim to highlight the trend toward robotic pyeloplasty over laparoscopy and current available evidence on outcomes. METHODS We systematically searched the PubMed and EMBASE databases, and we critically reviewed the available literature on the use of laparoscopy and robotic technology in pediatric patients with UPJO. RESULTS Overall, we selected 19 original articles and 5 meta-analyses. The available literature showed that the robotic approach to the UPJO allowed for decreased operative times, shorter length of hospital stay, lower complication rates, with success rates comparable to LP. Conflicting results persist regarding robotic platform and equipment costs. CONCLUSION While laparoscopy requires advanced skills for complex reconstructive procedures, such as pyeloplasty, robot-assisted surgery offers the valuable potential of making MIS more accessible to these types of procedure. Robotic technology has contributed to shortening the learning curve by acting as a bridge between open and endoscopic approach. There is still a strong need for higher quality evidence in the form of prospective observational studies and clinical trials, as well as further cost-effectiveness analyses. As robotic surgical technology spreads, future systems will be developed, offering smaller and more flexible tools, allowing enhanced applications on pediatric patients.
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Sforza S, Di Maida F, Mari A, Zaccaro C, Cini C, Tellini R, Carini M, Minervini A, Masieri L. Is a Drainage Placement Still Necessary After Robotic Reconstruction of the Upper Urinary Tract in Children? Experience from a Tertiary Referral Center. J Laparoendosc Adv Surg Tech A 2019; 29:1180-1184. [DOI: 10.1089/lap.2019.0302] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Simone Sforza
- Department of Pediatric Urology, University of Florence, Meyer Hospital, Florence, Italy
- Department of Oncologic, Minimally-Invasive Urology and Andrology, University of Florence, Careggi Hospital, Florence, Italy
| | - Fabrizio Di Maida
- Department of Oncologic, Minimally-Invasive Urology and Andrology, University of Florence, Careggi Hospital, Florence, Italy
| | - Andrea Mari
- Department of Oncologic, Minimally-Invasive Urology and Andrology, University of Florence, Careggi Hospital, Florence, Italy
| | - Claudia Zaccaro
- Department of Oncologic, Minimally-Invasive Urology and Andrology, University of Florence, Careggi Hospital, Florence, Italy
| | - Chiara Cini
- Department of Pediatric Urology, University of Florence, Meyer Hospital, Florence, Italy
| | - Riccardo Tellini
- Department of Oncologic, Minimally-Invasive Urology and Andrology, University of Florence, Careggi Hospital, Florence, Italy
| | - Marco Carini
- Department of Oncologic, Minimally-Invasive Urology and Andrology, University of Florence, Careggi Hospital, Florence, Italy
| | - Andrea Minervini
- Department of Oncologic, Minimally-Invasive Urology and Andrology, University of Florence, Careggi Hospital, Florence, Italy
| | - Lorenzo Masieri
- Department of Pediatric Urology, University of Florence, Meyer Hospital, Florence, Italy
- Department of Oncologic, Minimally-Invasive Urology and Andrology, University of Florence, Careggi Hospital, Florence, Italy
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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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Kawal T, Sahadev R, Srinivasan A, Chu D, Weiss D, Long C, Van Batavia J, Bodar Y, Shah J, Shukla AR. Robotic surgery in infants and children: an argument for smaller and fewer incisions. World J Urol 2019; 38:1835-1840. [PMID: 31016450 DOI: 10.1007/s00345-019-02765-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/06/2019] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Robotic-assisted laparoscopic (RAL) surgery has gained momentum in pediatric urology. Technological adaptations such as the development of 5 mm instruments have led to robotic procedures being performed on younger children and those having smaller body habitus, with improved cosmesis. However, concerns have been raised regarding decreased intra-abdominal working space and the absence of monopolar curved scissors (hot endoshears®) when using 5 mm instruments. The aim of this study is to examine the overall experience at a single pediatric urology center using 5 mm instruments with no planned additional assistant ports during common robotic procedures. We hypothesized this approach is safe and feasible for a variety of pediatric urologic reconstructive procedures. METHODS We retrospectively reviewed all major robotic procedures entered into an IRB approved data registry. The analysis was performed only for procedures in which 5 mm instruments were used exclusively with hook diathermy. Procedures that utilized 8 mm instrumentation were excluded from the study. Data were abstracted according to patient age, weight and robotic surgery performed. Outcomes included post-operative complications (Clavien-Dindo classification), operative time, operative blood loss, need for assistant port placement and conversion rates to open or pure laparoscopic surgery. RESULTS From 2012 to 2016, 220 consecutive pediatric RAL urological surgical cases were performed on 201 patients. These comprised pyeloplasty (n = 102) 46.4%, ureteral reimplants (n = 84) 38.2% and ipsilateral ureteroureterostomy (n = 34) 15.5%. Median age at surgery was 4 years (3 months to 18 years). There were no conversions to open or laparoscopic surgery. Placement of an additional Assist port was documented in seven cases. Severe (Clavien grade 4) complications occurred in two patients requiring ICU admission: one for sepsis and one ventilator-dependent patient having increased work of breathing post-op. Intra-operative blood loss was minimal ( < 50 ml) in 97% of cases. Patients ≤ 1 year of age comprised 28.6% of the study population. Univariate analysis revealed no association between age and occurrence of complications (p = 0.957) CONCLUSIONS: This study represents one of the largest series of consecutive RAL surgery using 5 mm instruments in pediatric urology. Acceptable complication rates, OR times and blood loss were achieved using this technique. We conclude that the use of 5 mm instruments gives excellent operative outcomes in pediatric reconstructive procedures.
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Affiliation(s)
- Trudy Kawal
- Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Ravindra Sahadev
- Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Arun Srinivasan
- Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - David Chu
- Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Dana Weiss
- Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Christopher Long
- Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Jason Van Batavia
- Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Yves Bodar
- Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Jay Shah
- Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Aseem R Shukla
- Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
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Andolfi C, Kumar R, Boysen WR, Gundeti MS. Current Status of Robotic Surgery in Pediatric Urology. J Laparoendosc Adv Surg Tech A 2019; 29:159-166. [DOI: 10.1089/lap.2018.0745] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Ciro Andolfi
- Pediatric Urology, Section of Urology, Department of Surgery, Comer Children's Hospital, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Rana Kumar
- Pediatric Urology, Section of Urology, Department of Surgery, Comer Children's Hospital, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - William R. Boysen
- Pediatric Urology, Section of Urology, Department of Surgery, Comer Children's Hospital, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Mohan S. Gundeti
- Pediatric Urology, Section of Urology, Department of Surgery, Comer Children's Hospital, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
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Kim SJ, Barlog JS, Akhavan A. Robotic-Assisted Urologic Surgery in Infants: Positioning, Trocar Placement, and Physiological Considerations. Front Pediatr 2019; 6:411. [PMID: 30666303 PMCID: PMC6330297 DOI: 10.3389/fped.2018.00411] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 12/10/2018] [Indexed: 12/30/2022] Open
Abstract
Pediatric robotic-assisted laparoscopic procedures are becoming increasingly common. They have been shown to be safe in younger patients, including infants. Successful adoption of robotic-assisted surgery in infants requires an understanding of the technical factors unique to this patient population. This review will delineate the specific considerations to safely perform robotic-assisted laparoscopic procedures in infants, including physiological changes associated with pneumoperitoneum in infants, positioning, trocar placement, and docking.
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Affiliation(s)
- Soo Jeong Kim
- Institute for Pediatric Urology, Komansky Children's Hospital, New York Presbyterian-Weill Cornell, New York, NY, United States
| | - John S. Barlog
- SUNY Downstate Medical Center, Brooklyn, NY, United States
| | - Ardavan Akhavan
- Institute for Pediatric Urology, Komansky Children's Hospital, New York Presbyterian-Weill Cornell, New York, NY, United States
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Morales-López RA, Pérez-Marchán M, Pérez Brayfield M. Current Concepts in Pediatric Robotic Assisted Pyeloplasty. Front Pediatr 2019; 7:4. [PMID: 30733937 PMCID: PMC6353791 DOI: 10.3389/fped.2019.00004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 01/09/2019] [Indexed: 02/06/2023] Open
Abstract
Robotic surgery in pediatric urology has been gaining popularity since its introduction almost two decades ago. Robotic assisted pyeloplasty is the most common robotic procedure performed in pediatric urology. Advances in robotic technology, instrumentation, patient care and surgical expertise have allowed the correction of ureteropelvic junction (UPJ) obstruction in most patients using this minimally invasive technique. The excellent experience with robotic assisted pyeloplasty has challenged other approaches as a new standard for the treatment of UPJ obstruction. In this review, we will describe the technique as it relates to the different robotic platforms, review the surgical experience and compare its results to other surgical approaches. Also, we will discuss patient and parent satisfaction, cost and financial considerations, along with evaluating the future of robotic surgery in the treatment of UPJ obstruction.
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Affiliation(s)
- Ramphis A Morales-López
- Division of Urology, Department of Surgery, University of Puerto Rico School of Medicine, San Juan, PR, United States.,HIMA-San Pablo Group, Caguas, PR, United States
| | - Marcos Pérez-Marchán
- Division of Urology, Department of Surgery, University of Puerto Rico School of Medicine, San Juan, PR, United States.,HIMA-San Pablo Group, Caguas, PR, United States
| | - Marcos Pérez Brayfield
- Division of Urology, Department of Surgery, University of Puerto Rico School of Medicine, San Juan, PR, United States.,HIMA-San Pablo Group, Caguas, PR, United States
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Chen CJ, Peters CA. Robotic Assisted Surgery in Pediatric Urology: Current Status and Future Directions. Front Pediatr 2019; 7:90. [PMID: 30972310 PMCID: PMC6443930 DOI: 10.3389/fped.2019.00090] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 03/01/2019] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Catherine J Chen
- Pediatric Urology, Children's Health System Texas, University of Texas Southwestern, Dallas, TX, United States
| | - Craig A Peters
- Pediatric Urology, Children's Health System Texas, University of Texas Southwestern, Dallas, TX, United States
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Kawal T, Srinivasan AK, Shrivastava D, Chu DI, Van Batavia J, Weiss D, Long C, Shukla AR. Pediatric robotic-assisted laparoscopic pyeloplasty: Does age matter? J Pediatr Urol 2018; 14:540.e1-540.e6. [PMID: 29909190 DOI: 10.1016/j.jpurol.2018.04.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 04/16/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although shown to be safe in infancy, robotic-assisted laparoscopic pyeloplasty (RALP) for ureteropelvic junction obstruction (UPJO) is most commonly performed in older children and adolescents. OBJECTIVE This study examined a contemporary RALP experience at a single tertiary pediatric center and compared outcomes in infants aged ≤1 year with an older cohort. METHODS AND DESIGN All RALP procedures were entered into an Institutional Review Board-approved data registry from 2012 to 2016. Patients were retrospectively grouped according to age. The primary outcome was success rate. Secondary outcomes included complications and length of hospital stay. Failure was defined as the need for secondary surgical intervention for UPJO or worsening urinary tract dilation on imaging. Statistical analysis was performed using SPSS version 20. Mann-Whitney U testing was used for comparison. RESULTS A total of 138 patients underwent RALP during 2012-2016, with a median age of 6 years (IQR 1, 13.25) and a male:female ratio of approximately 2:1. Of these, 34 (24.6%) were aged ≤1 year. Of all patients, 60 (43.5%) presented with a history of prenatal hydronephrosis, and 32% had a crossing vessel causing obstruction. An indwelling stent was placed in antegrade fashion in 71% of cases, and 18% had a percutaneously placed externalized stent. There were six (4%) failures requiring reoperation. Multivariate and comparative analysis demonstrated that the infant cohort utilized less morphine equivalents and more often had a percutaneous stent placed compared to the older cohort. Of the complications that occurred, 60% were minor (Clavien grades 1 and 2) and 40% were Clavien grade 3 in the infant cohort, and 70.1% and 29.9% in the older cohort, respectively. No studied criteria predicted failure in either cohort. CONCLUSION This study presented one of the largest contemporary series of consecutive pediatric RALPs, and showed an overall success rate of 96%. There were no significant differences in length of hospital stay, and complications or failure rates in infants compared to older children. This study substantiated the ongoing trend towards the adaptation of robotic-assisted surgery for the entire pediatric patient population.
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Affiliation(s)
- T Kawal
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - A K Srinivasan
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - D Shrivastava
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - D I Chu
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - J Van Batavia
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - D Weiss
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - C Long
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - A R Shukla
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, USA.
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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: 22] [Impact Index Per Article: 3.7] [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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Mizuno K, Kojima Y, Nishio H, Hoshi S, Sato Y, Hayashi Y. Robotic surgery in pediatric urology: Current status. Asian J Endosc Surg 2018; 11:308-317. [PMID: 30264441 DOI: 10.1111/ases.12653] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 08/21/2018] [Accepted: 08/23/2018] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Kentaro Mizuno
- Department of Pediatric Urology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yoshiyuki Kojima
- Department of Urology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hidenori Nishio
- Department of Pediatric Urology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Seiji Hoshi
- Department of Urology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yuichi Sato
- Department of Urology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yutaro Hayashi
- Department of Pediatric Urology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Abstract
Urinary tract dilatation (UTD) is the most common congenital anomaly detected on prenatal ultrasonography (US), affecting 1% to 3% of all pregnancies. This article focuses on the prenatal detection of UTD and the postnatal evaluation and management based on the UTD grading system risk assessment. Prophylactic antibiotics and postnatal imaging are discussed. The recent management trend is for a more conservative approach to minimize unnecessary testing and exposures to the fetus and neonate while detecting those who may have clinically significant disorder. The renal bladder US remains a critical part of the evaluation and helps guide further investigations.
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Affiliation(s)
- Andrea Balthazar
- Division of Urology, Department of Surgery, Virginia Commonwealth University School of Medicine, VCU Medical Center, PO Box 980118, Richmond, VA 23298-0118, USA
| | - C D Anthony Herndon
- Pediatric Urology, Division of Urology, Department of Surgery, Children's Hospital of Richmond, Virginia Commonwealth University School of Medicine, VCU Medical Center, PO Box 980118, Richmond, VA 23298-0118, USA.
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Bañuelos Marco B, Fuller TF, Friedersdorff F, González R, Lingnau A. Transperitoneal Mini-Laparoscopic Pyeloplasty in Flank Position: A Safe Method for Infants and Young Adults. Front Surg 2018; 5:32. [PMID: 29725594 PMCID: PMC5917372 DOI: 10.3389/fsurg.2018.00032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 04/03/2018] [Indexed: 12/29/2022] Open
Abstract
Introduction and Objectives Open dismembered pyeloplasty has been the gold standard treatment for ureteropelvic junction obstruction in children. Laparoscopic pyeloplasty (LP) is becoming a standard procedure, but its acceptance is slow. We report our method for minilaparoscopy (MLP) in children using a tansperitoneal approach with the patient in the lateral flank decubitus which we found technically advantageous. Materials and Methods Retrospective review of the records of 52 children and adolescents up to 18 years of age who underwent transperitoneal MLP at our institution during March 2012–October 2017 A 5 mm trocar is placed for the camera at the site of the umblicus by open technique, two 3 mm trocars placed in the upper and lower quadrants of the abdomen. No additional ports were necessary. 20cm long, 3-mm-diameter instruments are used. Few cases needed percutaneous fixation of the pelvis. The anastomosis is performed with 5–0 or 6–0 Polyglecaprone 25 (Monocryl®) with 13 mm half circle needle (TF plus) suture cut to 12–14 cm length and introduced through the 5-mm port. Needles are removed through the 3-mm port under direct vision. Results Fifty-two children (53 renal units) with a mean age of 82 months (range 3.5–204), a mean weight of 24,35 kg (range 7–57), and a mean follow-up of 20,44 months (6–60). Nine children were younger than 12 months, and 14 were ≤10kg. Six patients were >50kg. The mean of preoperative grade of dilatation was III (SFU scale) and postoperatively improved to SFU 0,60 (0–2). In 50 (94,3%) of the cases, there was complete resolution of hydronephrosis. There was no conversions to open surgery. Three patients suffered complications Clavien-Dindo Classification IIIb, 2 omental prolapses through a port site in two children which required general anaesthesia and one percutaneous drainage due to a leakage. No reinterventions related to stent complications or obstruction were found. Mean hospital stay was 4,69 (3–14) days. Conclusions The method of mini LP described here has proven efficient and safe. Weight appeared not to be limitation for both groups ≤10 and >50 kg.
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Affiliation(s)
| | | | | | | | - Anja Lingnau
- Urology, Charité Universitätsmedizin Berlin, Berlin, Germany
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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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Tam YH, Pang KKY, Wong YS, Chan KW, Lee KH. From Laparoscopic Pyeloplasty to Robot-Assisted Laparoscopic Pyeloplasty in Primary and Reoperative Repairs for Ureteropelvic Junction Obstruction in Children. J Laparoendosc Adv Surg Tech A 2018; 28:1012-1018. [PMID: 29641368 DOI: 10.1089/lap.2017.0561] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Robot-assisted laparoscopic pyeloplasty (RALP) and laparoscopic pyeloplasty (LP) are both minimally invasive surgical options to correct ureteropelvic junction obstruction in children. There are limited data reporting surgeons' experience of switching from LP to RALP and comparing the outcomes of the two procedures. METHODS We conducted a retrospective study on 63 consecutive children who underwent either LP or RALP by the same surgeon in a tertiary center from January 2008 to November 2016. LP had been the standard practice until January 2014 when it was replaced by RALP in short transition. RESULTS Thirty-seven LP and 26 RALP were successfully performed in children aged 2 months to 16 years. There was no difference between the two groups in age, body weight, laterality, clinical presentations, preoperative imagings, primary/reoperative repairs. The overall success rates were 34/37 (91.9%) and 25/26 (96.2%) for LP and RALP, respectively (P > .05). RALP was associated with shorter length of stay (3.1 days versus 4.0 days; P = .03). Surgeon-in-training participation was greater in RALP group (P < .001). There was no difference in operative time, complication rates, and analgesic requirement between the two groups. CONCLUSIONS Surgeons proficient in LP can adapt quickly to RALP, achieving comparable outcomes. Robotic technology may facilitate training on minimally invasive pyeloplasty.
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Affiliation(s)
- Yuk Him Tam
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong , Hong Kong, China
| | - Kristine Kit Yi Pang
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong , Hong Kong, China
| | - Yuen Shan Wong
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong , Hong Kong, China
| | - Kin Wai Chan
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong , Hong Kong, China
| | - Kim Hung Lee
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong , Hong Kong, China
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Takazawa S, Ishimaru T, Harada K, Deie K, Hinoki A, Uchida H, Sugita N, Mitsuishi M, Iwanaka T, Fujishiro J. Evaluation of Surgical Devices Using an Artificial Pediatric Thoracic Model: A Comparison Between Robot-Assisted Thoracoscopic Suturing Versus Conventional Video-Assisted Thoracoscopic Suturing. J Laparoendosc Adv Surg Tech A 2018; 28:622-627. [PMID: 29406817 DOI: 10.1089/lap.2017.0307] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Pediatric robot-assisted surgery is increasingly being performed, but it is difficult to perform this procedure in infants. A pediatric thoracoscopic model of a 1-year-old patient was developed in our previous study, and this model was used to evaluate the use of a surgical robot for infant surgery. METHODS Eight pediatric surgeons performed an intracorporeal suturing and knot-tying task using the da Vinci Xi Robotic Surgical System. The task completion time, number of needle manipulations, and force applied during suturing of the robot-assisted thoracoscopic surgery (RATS) group were compared with those of the video-assisted thoracoscopic surgery (VATS) group whose data had been collected from the same 8 surgeons in our previous study. RESULTS The RATS group showed a significantly shorter completion time than the VATS group in the knot-tying phase (P = .016) and in the total phase (P = .0078). The RATS group showed a significantly smaller number of manipulations than the VATS group in the total phase (P = .039). The RATS group showed a significantly smaller pushing force index than the VATS group in the suturing phase (P = .031), knot-tying phase (P = .031), and in the total phase (P = .031). A seventh rib in the model was dislocated in all RATS group cases. CONCLUSIONS The da Vinci Surgical System might be useful in infants because of fast movement and small pushing force. However, the robotic 8 mm instruments were too large for use in the thoracic cavity of the 1-year-old infant.
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Affiliation(s)
- Shinya Takazawa
- 1 Department of Pediatric Surgery, The University of Tokyo Hospital , Tokyo, Japan .,2 Department of Pediatric Surgery, Gunma Children's Medical Center , Shibukawa, Gunma, Japan
| | - Tetsuya Ishimaru
- 1 Department of Pediatric Surgery, The University of Tokyo Hospital , Tokyo, Japan .,3 Department of Pediatric Surgery, Saitama Children's Medical Center , Saitama, Japan
| | - Kanako Harada
- 4 Department of Mechanical Engineering, School of Engineering, The University of Tokyo , Tokyo, Japan
| | - Kyoichi Deie
- 1 Department of Pediatric Surgery, The University of Tokyo Hospital , Tokyo, Japan
| | - Akinari Hinoki
- 5 Department of Pediatric Surgery, Nagoya University Graduate School of Medicine , Nagoya, Aichi, Japan
| | - Hiroo Uchida
- 5 Department of Pediatric Surgery, Nagoya University Graduate School of Medicine , Nagoya, Aichi, Japan
| | - Naohiko Sugita
- 4 Department of Mechanical Engineering, School of Engineering, The University of Tokyo , Tokyo, Japan
| | - Mamoru Mitsuishi
- 4 Department of Mechanical Engineering, School of Engineering, The University of Tokyo , Tokyo, Japan
| | - Tadashi Iwanaka
- 1 Department of Pediatric Surgery, The University of Tokyo Hospital , Tokyo, Japan .,3 Department of Pediatric Surgery, Saitama Children's Medical Center , Saitama, Japan
| | - Jun Fujishiro
- 1 Department of Pediatric Surgery, The University of Tokyo Hospital , Tokyo, Japan
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Puttmann K, Huang GO, White JT, Kukreja K, Seth A, Koh CJ. Infant crossed renal ectopia with UPJ obstruction repaired via robot-assisted laparoscopic pyeloplasty. J Pediatr Urol 2018; 14:75-76. [PMID: 29133165 DOI: 10.1016/j.jpurol.2017.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 10/02/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION We present a robot-assisted approach to surgical treatment of UPJ obstruction associated with crossed renal ectopia in a male infant. METHODS A 31 year-old woman presented at 37 weeks gestation for prenatal hydronephrosis and delivered at 39 weeks. Renal ultrasound identified the bladder and right kidney in a crossed ectopic position in the left pelvis, and MRI showed the cystic lesion to be hydronephrosis associated with a ureteropelvic junction obstruction of the crossed ectopic right kidney. At three months of age, a robot-assisted laparoscopic dismembered pyeloplasty was performed. Post-operative renal ultrasounds at one, two, and 7 months showed persistent but decreasing hydronephrosis. He remains asymptomatic. DISCUSSION Crossed renal ectopia with associated ureteropelvic junction obstruction has been reported in the literature and managed using both open and minimally invasive approaches. To our knowledge, this is the first reported robot-assisted pyeloplasty performed for this condition in an infant. CONCLUSIONS With careful patient selection, the robot-assisted laparoscopic approach can be applied to infants that require pyeloplasty for kidneys with anomalous development that have evidence of ureteropelvic junction obstruction.
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Affiliation(s)
- K Puttmann
- Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - G O Huang
- Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - J T White
- Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - K Kukreja
- Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - A Seth
- Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - C J Koh
- Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA.
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Jackson JN, Zee RS, Martin AN, Corbett ST, Herndon CDA. A practice pattern assessment of members of the Society of Pediatric Urology for evaluation and treatment of urinary tract dilation. J Pediatr Urol 2017; 13:602-607. [PMID: 28506597 DOI: 10.1016/j.jpurol.2017.03.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 03/26/2017] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Over the last decade the literature, including a multidisciplinary consensus statement, has supported a paradigm shift in management of urinary tract dilation, yet the impact on practice patterns has not been well documented. OBJECTIVE This study aims to elucidate specific practice patterns for treatment of prenatal unilateral urinary tract dilation and to assess surgical intervention patterns for ureteropelvic junction obstruction. STUDY DESIGN An online survey was distributed to 234 pediatric urologists through the Society of Pediatric Urology. The survey was composed of five clinical case scenarios addressing evaluation and management of unilateral urinary tract dilation. RESULTS The response rate was 71% (n = 168). Circumcision status, gender, and grade were significant factors in recommending prophylactic antibiotics for newborn urinary tract dilation. Prophylactic antibiotic use in the uncircumcised male and female was twice that of a circumcised male for grade 3 (Table). This difference was minimized for grade 4. Use of VCUG was high for circumcised males with grade 3 or 4 (Table). The choice of minimally invasive surgery for ureteropelvic junction repair increased with age from 19% for a 5-month-old, 49% for a 2-year-old, and 85% for a 10-year-old. Notably, 44% of respondents would observe a 10-year-old with intermittent obstruction. Retrograde pyelography was recommended in conjunction with repair in 65% of respondents. Antegrade stent placement was the most common choice (38-47%) for urinary diversion after pyeloplasty. Regarding postoperative imaging, only 5% opted for routine renal scan whereas most would perform renal ultrasound alone. DISCUSSION Practice patterns seen for use of prophylactic antibiotics are in agreement with the literature, which promotes selective use in those at highest risk for urinary tract infections. Interestingly, use of aggressive screening was not concordant with this literature. Several studies have indicated an increased usage of robotic pyeloplasty; however, results indicate that minimally invasive surgery is not preferred in those younger than 6 months. Study limitations include use of clinical case scenarios as opposed to actual clinical practice. CONCLUSION Practice patterns for prophylactic antibiotic use for neonatal urinary tract dilation are dependent on gender, circumcision status, and grade. The use of minimally invasive surgery for ureteropelvic junction repair increased with patient age, with 50% preferring this modality at 2 years.
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Affiliation(s)
- Jessica N Jackson
- Department of Urology, University of Virginia, Charlottesville, VA, USA.
| | - Rebecca S Zee
- Department of Urology, University of Virginia, Charlottesville, VA, USA
| | - Allison N Martin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Sean T Corbett
- Department of Urology, University of Virginia, Charlottesville, VA, USA
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Boysen WR, Gundeti MS. Robot-assisted laparoscopic pyeloplasty in the pediatric population: a review of technique, outcomes, complications, and special considerations in infants. Pediatr Surg Int 2017; 33:925-935. [PMID: 28365863 DOI: 10.1007/s00383-017-4082-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2017] [Indexed: 12/16/2022]
Abstract
Ureteropelvic junction obstruction is a common condition encountered by the pediatric urologist, and treated with pyeloplasty when indicated. Recent technological advancements and a shift across all surgical fields to embrace minimally invasive surgery have led to increased utilization of minimally invasive pyeloplasty. Conventional laparoscopy is a reasonable choice, but its use is limited by the technical challenges of precise suturing in a confined space and the associated considerable learning curve. Robotic technology has simplified the minimally invasive approach to pyeloplasty, offering enhanced visualization and improved dexterity with a fairly short learning curve. As utilization of robotic pyeloplasty continues to increase, we sought to critically assess the literature on this approach. We begin with a review of the technical aspects of robot-assisted laparoscopic pyeloplasty including tips for surgical proficiency and patient safety. Outcomes and complications from the contemporary literature are reviewed, as well as special considerations in the pediatric population including infant pyeloplasty, cost concerns, training, and postoperative diversion/drainage.
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Affiliation(s)
- William R Boysen
- Pediatric Urology, Comer Children's Hospital, The University of Chicago Medicine and Biological Sciences, 5841 S. Maryland, P-217, MC 7122, Chicago, IL, 60637, USA
| | - Mohan S Gundeti
- Pediatric Urology, Comer Children's Hospital, The University of Chicago Medicine and Biological Sciences, 5841 S. Maryland, P-217, MC 7122, Chicago, IL, 60637, USA.
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Cundy TP, Harley SJD, Marcus HJ, Hughes-Hallett A, Khurana S. Global trends in paediatric robot-assisted urological surgery: a bibliometric and Progressive Scholarly Acceptance analysis. J Robot Surg 2017; 12:109-115. [PMID: 28455800 DOI: 10.1007/s11701-017-0703-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 04/24/2017] [Indexed: 12/23/2022]
Abstract
The inaugural robot-assisted urological procedure in a child was performed in 2002. This study aims to catalogue the impact of this technology by utilizing bibliographic data as a surrogate measure for global diffusion activity and to appraise the quality of evidence in this field. A systematic literature search was performed to retrieve all reported cases of paediatric robot-assisted urological surgery published between 2003 and 2016. The status of scientific community acceptance was determined using a newly developed analysis model named progressive scholarly acceptance. A total of 151 publications were identified that reported 3688 procedures in 3372 patients. The most reported procedures were pyeloplasty (n = 1923) and ureteral reimplantation (n = 1120). There were 16 countries and 48 institutions represented in the literature. On average, the total case volume reported in the literature more than doubled each year (mean value increase 236.6% per annum). The level of evidence for original studies remains limited to case reports, case series and retrospective comparative studies. Progressive Scholarly Acceptance charts indicate that robot-assisted techniques for pyeloplasty or ureteral reimplantation are yet to be accepted by the scientific community. Global adoption trends for robotic surgery in paediatric urology have been progressive but remain low volume. Pyeloplasty and ureteral reimplantation are dominant applications. Robot-assisted techniques for these procedures are not supported by high quality evidence at present. Next-generation robots are forecast to be smaller, cheaper, more advanced and customized for paediatric patients. Ongoing critical evaluation must occur simultaneously with expected technology evolution.
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Affiliation(s)
- Thomas P Cundy
- Discipline of Surgery, University of Adelaide, Adelaide, SA, Australia. .,Department of Paediatric Surgery, Women's and Children's Hospital, 72 King William Road, Adelaide, SA, 5006, Australia. .,The Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, UK.
| | - Simon J D Harley
- Discipline of Surgery, University of Adelaide, Adelaide, SA, Australia
| | - Hani J Marcus
- The Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, UK
| | - Archie Hughes-Hallett
- The Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, UK
| | - Sanjeev Khurana
- Department of Paediatric Surgery, Women's and Children's Hospital, 72 King William Road, Adelaide, SA, 5006, Australia
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