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Boswell TC. Advancements in Surgical Management of Megaureters. Curr Urol Rep 2024; 25:215-223. [PMID: 38954357 PMCID: PMC11306539 DOI: 10.1007/s11934-024-01214-8] [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: 05/29/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW To review and describe the recent evolution of surgery for the various types of pediatric megaureter. RECENT FINDINGS Megaureter management first relies on determining the underlying cause, whether by obstruction, reflux, or a combination, and then setting appropriate surgical indications because many cases do not require surgery as shown by observation studies. Endoscopic balloon dilation has been on the rise as a major treatment option for obstructive megaureter, while refluxing megaureters can also be treated by laparoscopic and robotic techniques, whether extravesically or transvesicoscopically. During ureteral reimplantation, tapering is sometimes necessary to address the enlarged ureter, but there are also considerations for not tapering or for tapering alternatives. Endoscopic and minimally invasive surgeries for megaureter have been the predominant focus of recent megaureter literature. These techniques still need collaborative prospective studies to better define which surgeries are best for patients needing megaureter interventions.
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Affiliation(s)
- Timothy C Boswell
- Department of Urology, Children's of Alabama and University of Alabama at Birmingham, 1600 7th Avenue South, Lowder Suite 318, Birmingham, AL, 35233, USA.
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Feng S, Yu Z, Yang Y, Bi Y, Luo J. Minimally Invasive versus Open Ureteral Reimplantation in Children: A Systematic Review and Meta-Analysis. Eur J Pediatr Surg 2024; 34:245-252. [PMID: 36882103 DOI: 10.1055/s-0043-1764321] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
PURPOSE We performed a systematic review and meta-analysis to compare the safety and efficacy of minimally invasive surgery (MIS) versus open ureteral reimplantation (OUR) in children. METHODS Literature searches were conducted to identify studies that compared MIS (laparoscopic ureteral reimplantation or robot-assisted laparoscopic ureteral replantation) and OUR in children. Parameters such as operative time, blood loss, length of hospital stay, success rate, postoperative urinary tract infection (UTI), urinary retention, postoperative hematuria, wound infection, and overall postoperative complications were pooled and compared by meta-analysis. RESULTS Among the 7,882 pediatric participants in the 14 studies, 852 received MIS, and 7,030 received OUR. When compared with the OUR, the MIS approach resulted in shorter hospital stays (I 2 = 99%, weighted mean difference [WMD] -2.82, 95% confidence interval [CI] -4.22 to -1.41; p < 0.001), less blood loss (I 2 = 100%, WMD -12.65, 95% CI -24.82 to -0.48; p = 0.04), and less wound infection (I 2 = 0%, odds ratio 0.23, 95% CI 0.06-0.78; p = 0.02). However, no significant difference was found in operative time and secondary outcomes such as postoperative UTI, urinary retention, postoperative hematuria, and overall postoperative complications. CONCLUSION MIS is a safe, feasible, and effective surgical procedure in children when compared with OUR. Compared with OUR, MIS has a shorter hospital stay, less blood loss, and less wound infection. Furthermore, MIS is equivalent to OUR in terms of success rate and secondary outcomes such as postoperative UTI, urinary retention, postoperative hematuria, and overall postoperative complications. We conclude that MIS should be considered an acceptable option for pediatric ureteral reimplantation.
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Affiliation(s)
- Shaoguang Feng
- Department of Pediatric Surgery, Hangzhou Children's Hospital, Hangzhou, China
- Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Zhechen Yu
- Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yicheng Yang
- Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yunli Bi
- Department of Pediatric Urology, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Jinjian Luo
- Department of Pulmonary and Critical Care Medicine (PCCM), Anji County People's Hospital, Huzhou, Zhejiang, China
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3
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Sforza S, Marco BB, Haid B, Baydilli N, Donmez MI, Spinoit AF, Paraboschi I, Masieri L, Steinkellner L, Comez YI, Lammers RJM, 't Hoen LA, O'Kelly F, Bindi E, Kibar Y, Silay MS. A multi-institutional European comparative study of open versus robotic-assisted laparoscopic ureteral reimplantation in children with high grade (IV-V) vesicoureteral reflux. J Pediatr Urol 2024; 20:283-291. [PMID: 38000950 DOI: 10.1016/j.jpurol.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 09/27/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023]
Abstract
INTRODUCTION Traditionally, open ureteral reimplantation (OUR) has been the standard treatment for primary vesicoureteral reflux (VUR) requiring reimplantation. Robotic-assisted laparoscopic ureteral reimplantation (RALUR) is gaining popularity and high success rates have been reported. OBJECTIVE In this multi-institutional study, we aimed to compare the perioperative and postoperative outcomes of OUR and RALUR for high-grade (IV + V) VUR in children. STUDY DESIGN A retrospective evaluation was performed collecting data from 135 children (0-18 years) who underwent high grade VUR surgical correction at nine European institutions between 01/01/2009 and 01/12/2020, involving either open or robotic approaches. Institutional review board approval was obtained. Patients with lower grades of VUR (≤III), previous history of open or endoscopic ureteral surgery, neurogenic bladder, or refluxing megaureter in need of ureteral tapering were excluded. Pre-, peri- and post-operative data were statistically compared. RESULTS Overall, 135 children who underwent either OUR (n = 68), or RALUR (n = 67) were included, and their clinic and demographic features were collected. The mean age of the open group was 11 months (interquartile range [IQR] 9.9-16.6 months), in the RALUR group it was 59 months (IQR 29-78mo) (p < 0.01); the open cohort had a weight of 11 kg (IQR 9.9-16.6 kg) while the RALUR group had 19 kg (IQR 13-25 kg) (p < 0.01). No significant differences were found for intraoperative (1.5 % vs 7.5 %, p = 0.09) or for postoperative complication rates (7.4 % vs 9 %, p = 0.15). Favorable outcomes were reported in the RALUR group: shorter time to stooling (1 vs 2 days), fewer indwelling urethral catheter days (1 vs 5 days), perioperative drain insertion time (1 vs 5 days) and a shorter length of hospital stay (2 vs 5 days) (p < 0.01). The success rate was 94.0 % and 98.5 % in the open and RALUR groups, respectively. The long-term clinical success rates from both groups was comparable:42 vs 23 months for open and RALUR, respectively. DISCUSSION This study reported a large multicentric experience focusing on high grade VUR. Furthermore, this study compares favorably to OUR in a safety analysis. There was also a trend towards higher success rates with RALUR utilizing an extravesical approach which has not been previously reported. CONCLUSION RALUR is an efficacious and safe platform to use during ureteral reimplantation for high grade VUR. The overall peri-operative and post-operative complication rates are at least equivalent to OUR, but it is associated with a faster functional recovery and time to discharge. Medium to long term success rates are also equivalent to OUR.
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Affiliation(s)
- Simone Sforza
- Department of Pediatric Urology, University of Florence, Meyer Children Hospital, Florence, Italy.
| | - Beatriz Bañuelos Marco
- Department of Urology, Charité University Clinic, Division of Paediatric Urology, Berlin, Germany
| | - Bernhard Haid
- Department of Pediatric Urology, Ordensklinikum Linz, Hospital of the Sisters of Charity, Linz, Austria
| | - Numan Baydilli
- Department of Pediatric Urology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Muhammet Irfan Donmez
- Division of Pediatric Urology, Department of Urology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Anne-Françoise Spinoit
- Department Urology ERN Centre, Ghent University Hospital, Ghent University, 9000 Ghent, Belgium
| | - Irene Paraboschi
- Department of Pediatric Urology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Lorenzo Masieri
- Department of Pediatric Urology, University of Florence, Meyer Children Hospital, Florence, Italy
| | - Lukas Steinkellner
- Department of Pediatric Urology, Ordensklinikum Linz, Hospital of the Sisters of Charity, Linz, Austria
| | - Yusuf Ilker Comez
- Department of Urology, Biruni University, Division of Paediatric Urology, Istanbul, Turkey
| | - Rianne J M Lammers
- Department of Urology, University Medical Center Groningen, 9713 GZ Groningen, the Netherlands
| | - Lisette Aimée 't Hoen
- Department of Paediatric Urology, Sophia Children's Hospital, Erasmus University Medical Center, 3015 GD Rotterdam, the Netherlands
| | - Fardod O'Kelly
- Division of Paediatric Urology, Beacon Hospital, DK18 AK68 Dublin, Ireland
| | - Edoardo Bindi
- Pediatric Surgery Unit, Salesi Children's Hospital, Ancona, Italy
| | - Yusuf Kibar
- Department of Urology, University, Koru Hospital, Ankara, Turkey
| | - Mesrur Selçuk Silay
- Department of Urology, Biruni University, Division of Paediatric Urology, Istanbul, Turkey
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He Y, Lin S, Xu X, He S, Xu H, You G, Chen J, Xu D. Single-port-plus-one robot-assisted laparoscopic modified Lich-Gregoir direct nipple ureteral extravesical reimplantation in children with a primary obstructive megaureter. Front Pediatr 2023; 11:1238918. [PMID: 38027297 PMCID: PMC10653315 DOI: 10.3389/fped.2023.1238918] [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: 06/12/2023] [Accepted: 09/21/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose To introduce a new technique of single-port-plus-one robotic laparoscopic-modified Lich-Gregoir direct nipple ureteral extravesical reimplantation and ascertain its validity in the treatment of pediatric primary obstructive megaureter. Methods Between January 2021 and November 2021, we retrospectively analyzed the clinical data of 12 children with primary obstructive megaureter who were admitted to the Department of Pediatric Surgery of Fujian Provincial Hospital. All 12 children were treated with single-port-plus-one robotic laparoscopic Lich-Gregoir direct nipple ureteral extravesical reimplantation. Five of them were female and seven were male, including nine cases were simple obstructive type, while the remaining three cases were obstructive with reflux type. The mean age of the children was 17.33 ± 6.99 (10-36) months and the mean follow-up time was 14.16 ± 1.75 (12-17) months. Changes in preoperative and first-year postoperative parameters were compared. Results The mean operative time for all 12 children was 123.58 ± 10.85 (110-145) min, with a mean internal operative time of 101.42 ± 0.85 (90-120) min, a mean operative bleeding time of 2.42 ± 0.67 (2-4) ml, and a mean hematuria duration of 16.08 ± 1.44 (14-19) h. The mean indwelling catheterization time was 2.25 ± 0.45 (2-3) days and the mean hospitalization time was 3.83 ± 0.39 (3-4) days. At the postoperative first year, the ureteral diameter, calyceal diameter, and anterior-posterior renal pelvic diameter were found to be significantly smaller than at the preoperative period (18.83 ± 3.21 mm vs. 6.83 ± 1.27 mm, 13.99 ± 3.58 mm vs. 3.5 ± 2.90 mm, and 34.92 ± 4.25 mm vs. 10.08 ± 1.88 mm, P < 0.001). There was a significant increase in renal cortical thickness and the percentage of differential renal function (3.63 ± 1.66 mm vs. 5.67 ± 1.88 mm, 33.75 ± 2.77 mm vs. 37.50 ± 1.31 mm, P < 0.001). The resolution rate of obstruction was 100% and no child developed DeNovo vesicoureteral reflux. Conclusion The technique of modified Lich-Gregoir direct nipple ureteral extravesical reimplantation can help maintain the physiological direction of the ureter and at the same time enhance the effectiveness of antirefluxing in robotic surgery. The design of a single-port-plus-one wound can produce a cosmetic appearance by concentrating and hiding the wound around the umbilicus. This modified reimplantation procedure has the potential to become a promising technique in the robot-assisted treatment of primary obstructive megaureter.
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Affiliation(s)
- Yufeng He
- Department of Pediatric Surgery, Children Medical Center, Fujian Provincial Hospital, Fuzhou, China
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Shan Lin
- Department of Pediatric Surgery, Children Medical Center, Fujian Provincial Hospital, Fuzhou, China
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Xinru Xu
- Department of Pediatric Surgery, Children Medical Center, Fujian Provincial Hospital, Fuzhou, China
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Shaohua He
- Department of Pediatric Surgery, Children Medical Center, Fujian Provincial Hospital, Fuzhou, China
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Huihuang Xu
- Department of Pediatric Surgery, Children Medical Center, Fujian Provincial Hospital, Fuzhou, China
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Guangxu You
- Department of Pediatric Surgery, Children Medical Center, Fujian Provincial Hospital, Fuzhou, China
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Jianglong Chen
- Department of Pediatric Surgery, Children Medical Center, Fujian Provincial Hospital, Fuzhou, China
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Di Xu
- Department of Pediatric Surgery, Children Medical Center, Fujian Provincial Hospital, Fuzhou, China
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
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Molinaro F, Nascimben F, Todesco C, Fusi G, Chiarella E, Planchamp T, Cobellis G, Abbo O, Messina M, Angotti R. Robotic approach to the uretero-vesical junction in children: An international multicentric retrospective study. Int J Med Robot 2023; 19:e2539. [PMID: 37260098 DOI: 10.1002/rcs.2539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 05/17/2023] [Accepted: 05/22/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Robot-assisted approach to UVJ is getting more and more used in pediatric patients. METHODS In this retrospective study 26 patients affected by nephro-urological malformations, robotic-surgically treated from 2016 and 2021 at 3 Pediatric Surgery Department were included: 3 (11.5%) primary obstructive megaureter, 2 (7.7%) dysplastic kidneys, 3 (11.5%) duplex collecting system, 18 (69.2%) primary vescico-ureteral reflux (VUR). RESULTS Mean age at surgery was 6 years old. 22 (84.6%) underwent Lich Gregoire extravesical ureteral reimplantation, 4 (15.4%) total nephroureterectomy. Mean operative time was 230 min. No conversions or intraoperative complications. Median hospital stay was 4 days. There were 4 (15.38%) postoperative complications: 3 (11.54%) persistent VUR and 1 (3.84%) refluxing megaureter. 2 (7.7%) redo-surgery. CONCLUSIONS Robotic Surgery should be considered a safe and effective technique for treatment of UVJ anomalies in children, because it firstly allows surgeons to approach both upper and lower ureteral ends without modifying trocars' placement.
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Affiliation(s)
- Francesco Molinaro
- Department of Medical Sciences, Surgery and Neuroscience, Section of Pediatric Surgery, University of Siena, Siena, Italy
| | - Francesca Nascimben
- Department of Medical Sciences, Surgery and Neuroscience, Section of Pediatric Surgery, University of Siena, Siena, Italy
| | - Camilla Todesco
- Department of Medical Sciences, Surgery and Neuroscience, Section of Pediatric Surgery, University of Siena, Siena, Italy
- Pediatric Surgery, Salesi Children Hospital, Università Politecnica Delle Marche, Ancona, Italy
| | - Giulia Fusi
- Department of Medical Sciences, Surgery and Neuroscience, Section of Pediatric Surgery, University of Siena, Siena, Italy
- Service de Chirurgie Pédiatrique, Hôpital des Enfants, Toulouse, France
| | - Elisa Chiarella
- Department of Medical Sciences, Surgery and Neuroscience, Section of Pediatric Surgery, University of Siena, Siena, Italy
| | | | - Giovanni Cobellis
- Pediatric Surgery, Salesi Children Hospital, Università Politecnica Delle Marche, Ancona, Italy
| | - Olivier Abbo
- Service de Chirurgie Pédiatrique, Hôpital des Enfants, Toulouse, France
| | - Mario Messina
- Department of Medical Sciences, Surgery and Neuroscience, Section of Pediatric Surgery, University of Siena, Siena, Italy
| | - Rossella Angotti
- Department of Medical Sciences, Surgery and Neuroscience, Section of Pediatric Surgery, University of Siena, Siena, Italy
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Esposito C, Masieri L, Fourcade L, Ballouhey Q, Varlet F, Scalabre A, Castagnetti M, El Ghoneimi A, Escolino M. Pediatric robot-assisted extravesical ureteral reimplantation (revur) in simple and complex ureter anatomy: Report of a multicenter experience. J Pediatr Urol 2023; 19:136.e1-136.e7. [PMID: 36344364 DOI: 10.1016/j.jpurol.2022.10.024] [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: 04/08/2022] [Revised: 08/04/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Robot-assisted extravesical ureteral reimplantation (REVUR) is a well established approach for surgical treatment of pediatric vesicoureteral reflux (VUR). However, further evidence is needed to confirm its efficacy even in case of complex anatomy. OBJECTIVE This study aimed to further confirm the evidence that REVUR is safe and effective in both simple and complex ureter anatomy. STUDY DESIGN The charts of all patients with VUR, who received REVUR in 6 different institutions over a 5-year period, were retrospectively reviewed. Patients with both simple and complex ureter anatomy were included. Patient demographics, surgical variables, and post-operative results were assessed. VUR resolution was defined as either being resolved VUR on voiding cystourethrogram (VCUG) or clinically without symptoms during the follow-up. RESULTS Fifty-seven patients with median age of 6.9 years (range 4.5-12), receiving REVUR in the study period, were included. Eighteen (31.6%) patients had complex anatomy and included prior failed endoscopic injection (n = 13), complete ureteral duplication (n = 2), periureteral diverticulum (n = 2), ectopic megaureter requiring dismembering (n = 1). The median operative time was 155 min for unilateral and 211.5 min for bilateral repairs. The clinical + radiographic VUR resolution rate was 96.5%. Post-operative complications (Clavien 2) included urinary retention following bilateral repair (n = 5, 8.7%), febrile urinary tract infection (UTI) (n = 6, 10.5%) and gross hematuria (n = 3, 5.2%). Comparative analysis between simple and complex cases showed that REVUR was faster in simple cases in both unilateral [p = 0.002] and bilateral repair [p = 0.001] and post-operative urinary retention was more frequent in simple cases [p = 0.004] and in patients with pre-operative bowel and bladder dysfunction (BBD) [p = 0.001] (Table). DISCUSSION This series confirmed that the robot-assisted technique was feasible even in cases with complex anatomy using some technical refinements, that justified the longer operative times in both unilateral and bilateral cases. An interesting finding of this study was the correlation emerged between BBD and risk of post-operative urinary retention and VUR persistence. Our results also excluded any significant correlation between complex cases and risk of post-operative urinary retention. The main study limitations included the retrospective and nonrandomized design, the small number of cases and the arbitrary definition of complex anatomy. CONCLUSION REVUR was safe and effective for management of VUR in both simple and complex ureter anatomy. Complex REVUR required slightly longer operative times, without significant differences in post-operative mordidity and success rates. Aside from complex anatomy, BBD emerged as the main risk factor associated with surgical failure and post-operative morbidity.
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Affiliation(s)
- Ciro Esposito
- Division of Pediatric Surgery, Federico II University Hospital, Naples, Italy.
| | - Lorenzo Masieri
- Division of Pediatric Urology, Meyer University Hospital, Florence, Italy
| | - Laurent Fourcade
- Division of Pediatric Surgery, CHU de Limoges, Hopital de la Mère et de l'Enfant, Limoges, France
| | - Quentin Ballouhey
- Division of Pediatric Surgery, CHU de Limoges, Hopital de la Mère et de l'Enfant, Limoges, France
| | - Francois Varlet
- Division of Pediatric Surgery, Centre Hospitalier Universitaire de Saint-Étienne, Saint-Étienne, France
| | - Aurelien Scalabre
- Division of Pediatric Surgery, Centre Hospitalier Universitaire de Saint-Étienne, Saint-Étienne, France
| | - Marco Castagnetti
- Division of Pediatric Urology, Bambino Gesù Children Hospital, Rome, Italy
| | - Alaa El Ghoneimi
- Department of Pediatric Surgery and Urology, University Hospital Robert Debrè, APHP, Paris, France
| | - Maria Escolino
- Division of Pediatric Surgery, Federico II University Hospital, Naples, Italy
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Esposito C, Masieri L, Autorino G, Escolino M. Robot-assisted extravesical ureteral reimplantation with ureteral tailoring and dismembering for complex obstructed megaureter. Asian J Urol 2023; 10:101-102. [PMID: 36721686 PMCID: PMC9875147 DOI: 10.1016/j.ajur.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/26/2021] [Accepted: 01/04/2022] [Indexed: 02/03/2023] Open
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Zhu W, Zhou H, Cao H, Li P, Tao Y, Ma L, Tao T, Zhou X, Zhao Y, Guo T, Han C, Zhuo R, Lv X, Cheng W, Feng Z. Modified technique for robot-assisted laparoscopic infantile ureteral reimplantation for obstructive megaureter. J Pediatr Surg 2022; 57:1011-1017. [PMID: 35717252 DOI: 10.1016/j.jpedsurg.2022.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/30/2022] [Accepted: 05/10/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE To describe a novel modification of technique to improve efficacy of robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) in infants. MATERIALS AND METHODS Between April 2017 and July 2019, sixteen infants with primary obstructive megaureter (POM) (Age range: 4-12 months) underwent robot-assisted ureteral reimplantation were reviewed in this series. In addition to the conventional Lich-Gregoir technique, the detrusor tunnel has been extended to the mobilized anterior bladder wall to guarantee sufficient tunnel length/ureter diameter ratio and avoid ureteral angulation. All patients underwent repeated ultrasound, diuretic renal dynamic imaging and voiding cystourethrography (VCUG) perioperatively and the outcomes were documented. RESULTS All operations were completed with robotic assisted approach without conversion. Bilateral and unilateral reimplantation were respectively performed in two and fourteen patients. The mean operative time was 115.0 ± 19.5 min and the mean blood loss was 10.0 ± 1.8 ml. There were no high-grade complications (III-IV on Clavien-Dindo classification) except for one patient. The distal ureteric diameter was reduced from pre operative 1.7 ± 0.5 to 0.6 ± 0.5 cm 6 months post operatively (p < 0.05). One child (6.3%) required the second reimplantation for stenosis. The overall operative success rate was 94.4% (17 of 18 ureters) with a mean follow-up of 15.9 ± 7.4 months with no flux detected. CONCLUSION Our preliminary experience suggests that our modified robot-assisted laparoscopic extravesical ureteral reimplantation is feasible in infants with good results.
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Affiliation(s)
- Weiwei Zhu
- Department of Urology, the Seventh Medical Centre, Chinese PLA General Hospital, No.5 Nan Mencang, Dongcheng District, Beijing 100700, China
| | - Huixia Zhou
- Department of Urology, the Seventh Medical Centre, Chinese PLA General Hospital, No.5 Nan Mencang, Dongcheng District, Beijing 100700, China.
| | - Hualin Cao
- Department of Urology, Nan Xi Shan Hospital of Guangxi Zhuangzu Autonomous Region, Guilin 541002, China
| | - Pin Li
- Department of Urology, the Seventh Medical Centre, Chinese PLA General Hospital, No.5 Nan Mencang, Dongcheng District, Beijing 100700, China
| | - Yuandong Tao
- Department of Urology, the Seventh Medical Centre, Chinese PLA General Hospital, No.5 Nan Mencang, Dongcheng District, Beijing 100700, China
| | - Lifei Ma
- Department of Urology, the Seventh Medical Centre, Chinese PLA General Hospital, No.5 Nan Mencang, Dongcheng District, Beijing 100700, China
| | - Tian Tao
- Department of Urology, the Seventh Medical Centre, Chinese PLA General Hospital, No.5 Nan Mencang, Dongcheng District, Beijing 100700, China
| | - Xiaoguang Zhou
- Department of Urology, the Seventh Medical Centre, Chinese PLA General Hospital, No.5 Nan Mencang, Dongcheng District, Beijing 100700, China
| | - Yang Zhao
- Department of Urology, the Seventh Medical Centre, Chinese PLA General Hospital, No.5 Nan Mencang, Dongcheng District, Beijing 100700, China
| | - Tao Guo
- Department of Urology, the Seventh Medical Centre, Chinese PLA General Hospital, No.5 Nan Mencang, Dongcheng District, Beijing 100700, China
| | - Ce Han
- Department of Urology, the Seventh Medical Centre, Chinese PLA General Hospital, No.5 Nan Mencang, Dongcheng District, Beijing 100700, China
| | - Ran Zhuo
- Department of Urology, the Seventh Medical Centre, Chinese PLA General Hospital, No.5 Nan Mencang, Dongcheng District, Beijing 100700, China
| | - Xuexue Lv
- Department of Urology, the Seventh Medical Centre, Chinese PLA General Hospital, No.5 Nan Mencang, Dongcheng District, Beijing 100700, China
| | - Wei Cheng
- New Century Healthcare Medical Center (Hong Kong), Hong Kong 999077, China
| | - Zhichun Feng
- Department of Urology, the Seventh Medical Centre, Chinese PLA General Hospital, No.5 Nan Mencang, Dongcheng District, Beijing 100700, China
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Mattioli G, Lena F, Fiorenza V, Carlucci M. Robotic ureteral reimplantation and uretero-ureterostomy treating the ureterovesical junction pathologies in children: technical considerations and preliminary results. J Robot Surg 2022; 17:659-667. [PMID: 36287349 DOI: 10.1007/s11701-022-01478-7] [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: 05/15/2022] [Accepted: 10/14/2022] [Indexed: 11/25/2022]
Abstract
Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR) and robotic ureteroureterostomy (RUU) are two mini-invasive surgical techniques that have begun to be performed in pediatric urology in recent years. RALUR has been employed especially for VUR treatment, while RUU is considered principally in case of complex doubled ureteral systems. Our aim is to discuss the safety and feasibility of these approaches in children, focusing on technical considerations and supporting their use in different anomalies and pathologies of the ureterovesical junction. We retrospectively collected data about 58 patients who underwent 44 dismembered RALUR (D-RALUR), 28 non-dismembered RALUR (ND-RALUR) and 5 RUU between May 2020 and December 2021. Indications for surgery were primary or secondary vesicoureteral reflux, megaureter, secondary UVJ obstructions, complicated doubled ureteral systems. Mean age was 3.5 years (range 0.6-12.9) and mean weight 17.1 (range 7.2-80). No intraoperative complications occurred nor conversion to open approach were reported. Major postoperative complications were reported in 11.7% of cases with a higher incidence for ND-RALUR. Mean hospital stay was 2.14 days (range 1-8). Success rate at the short-term follow-up was 91.9% for D-RALUR, 96.3% for ND-RALUR and 100% for RUU. RALUR and RUU are two feasible and safe procedures to perform in children. RALUR represents the most required and adequate technique in the treatment of UVJ pathologies, however, in selected cases RUU could represent an effective alternative that has to be considered.
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Affiliation(s)
- G Mattioli
- University of Genoa, DINOGMI, Genoa, Italy
- Pediatric Surgery Unit, IRCCS Istituto Giannina Gaslini, Via G. Gaslini 5, 16147, Genoa, Italy
| | - F Lena
- University of Genoa, DINOGMI, Genoa, Italy
- Pediatric Surgery Unit, IRCCS Istituto Giannina Gaslini, Via G. Gaslini 5, 16147, Genoa, Italy
| | - V Fiorenza
- University of Genoa, DINOGMI, Genoa, Italy
- Pediatric Surgery Unit, IRCCS Istituto Giannina Gaslini, Via G. Gaslini 5, 16147, Genoa, Italy
| | - Marcello Carlucci
- Pediatric Surgery Unit, IRCCS Istituto Giannina Gaslini, Via G. Gaslini 5, 16147, Genoa, Italy.
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Fan G, Li K, Wang Y, Zhao Y, Wang Z. Efficacy and safety of robot-assisted laparoscopic, laparoscopic and open surgery in ureteral reimplantation: a network meta-analysis and systematic review. Updates Surg 2022; 74:1491-1499. [PMID: 35925510 DOI: 10.1007/s13304-022-01344-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/27/2022] [Indexed: 10/16/2022]
Abstract
To compare the efficacy and safety between open ureteral replantation (OUR), laparoscopic ureteral replantation (LUR) and robot-assisted laparoscopic ureteral replantation (RALUR). This review produced by the R3.5.0 software with "gemtc" program package and JAGS3.4.0 software based on the Bayesian model. A comprehensive search was done in databases including PubMed, Web of Science, Embase, Cochrane library, Cnki, CBM and WANFANG DATA. Studies that compared OUR, LUR OR RALUR were selected. Summary of Conclusions by ranking of Outcomes. A total of 3949 patients from 29 studies were included. The success rate in OUR, LUR and RALUR was 97.72%, 94.68% and 95.82%. The OR (95% CI) of LUR and RALUR was 0.76 (0.42,1.7) and 0.76 (0.30, 2.6), respectively, compared with OUR. The rate of complications in OUR, LUR and RALUR was 12.78%, 7.94% and 16.32%. The OR (95% CI) of LUR and RALUR was 0.28 (0.16, 0.48) and 0.61 (0.24,1.3), respectively, compared with OUR. The MD (95% CI) of LUR and RALUR for operation time was 22 (2,40) and 46 (7.5,84), respectively, compared with OUR. The MD (95% CI) of LUR and RALUR for hospital stay was - 3.6 (- 4.5, - 2.7) and - 1.1 (- 2.9, 0.58), respectively, compared with OUR. There is no significant difference in the success rates of OUR, LUR, and RALUR. RALUR and OUR has similar complication rates and time of hospital stay, while LUR has fewer complications and faster time to discharge compared to RALUR and OUR. The operative time of OUR is significantly less compared to LUR and RALUR.
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Affiliation(s)
- Guangrui Fan
- Institute of Urology, Lanzhou University Second Hospital, Key Laboratory of Urological Diseases in Gansu Province, Gansu Nephro-Urological Clinical Center, 82 Cuiying Gate, Lanzhou, 730030, Gansu, People's Republic of China
| | - Kun Li
- Institute of Urology, Lanzhou University Second Hospital, Key Laboratory of Urological Diseases in Gansu Province, Gansu Nephro-Urological Clinical Center, 82 Cuiying Gate, Lanzhou, 730030, Gansu, People's Republic of China.,Panzhihua Central Hospital, Panzhihua, 617000, Sichuan, People's Republic of China
| | - Yuhan Wang
- Institute of Urology, Lanzhou University Second Hospital, Key Laboratory of Urological Diseases in Gansu Province, Gansu Nephro-Urological Clinical Center, 82 Cuiying Gate, Lanzhou, 730030, Gansu, People's Republic of China
| | - Youli Zhao
- Institute of Urology, Lanzhou University Second Hospital, Key Laboratory of Urological Diseases in Gansu Province, Gansu Nephro-Urological Clinical Center, 82 Cuiying Gate, Lanzhou, 730030, Gansu, People's Republic of China
| | - Zhiping Wang
- Institute of Urology, Lanzhou University Second Hospital, Key Laboratory of Urological Diseases in Gansu Province, Gansu Nephro-Urological Clinical Center, 82 Cuiying Gate, Lanzhou, 730030, Gansu, People's Republic of China.
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11
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Incidence and resolution of de novo hydronephrosis after pediatric robot-assisted laparoscopic extravesical ureteral reimplantation for primary vesicoureteral reflux. J Pediatr Urol 2022; 18:517.e1-517.e5. [PMID: 35654725 DOI: 10.1016/j.jpurol.2022.04.005] [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: 12/14/2021] [Revised: 03/03/2022] [Accepted: 04/03/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION With the advent of robot-assisted laparoscopic ureteral reimplantation (RALUR) for primary vesicoureteral reflux (VUR), understanding and minimizing its complications continues to be critical. Incidence of de novo hydronephrosis after RALUR could be indicative of an outcome that needs further study or could be a benign transient finding. OBJECTIVE In the present study, we hypothesized that the incidence of de novo hydronephrosis after RALUR is low and resolves spontaneously. METHODS An IRB-approved prospective single-institutional registry was utilized to identify all patients undergoing RALUR via an extravesical approach from 2012 to 2020. Patients with primary VUR and minimal (Grade I SFU) or no hydronephrosis prior to surgery were included. Patients who had other associated pathology or underwent concomitant procedures were excluded. Preoperative characteristics including VUR and hydronephrosis grades as well as post-operative clinical details and hydronephrosis grades were aggregated and analyzed. RESULTS 86/172 (50%) patients (133 ureters), with median reflux grade of 3 (IQR: G2, G3) met the inclusion criteria. Patients underwent RALUR at a median age of 5.7 years (IQR: 3.4, 8.7) with median 36.2 months (IQR: 19.6, 63.6) follow-up. Renal ultrasound at 4-6 weeks post-op showed de novo hydronephrosis in 18 (13.5%) ureters; the complete resolution was seen in 13 ureters (72%) at a median of 4.5 months from surgery. Among the 5 with non-resolved hydronephrosis (SFU G2:4, G3:1), 2 patients (3 ureters) underwent subsequent interventions. DISCUSSION The present study evaluating the natural history of de novo hydronephrosis after RALUR-EV performed for primary VUR, is to our knowledge the largest cohort of patients undergoing RALUR that this has been studied in. In our cohort, the incidence of de novo hydronephrosis after RALUR was 13.5%, similar to rates reported in two OUR cohorts, and significantly lower than reported incidence rates of 22-26% in several OUR cohorts, and 30% in a RALUR cohort. In the present cohort, hydronephrosis resolved spontaneously in more than 72% of cases. The median time from surgery until resolution of hydronephrosis was 4.5 (1.6, 10.5) months, which is shorter in comparison to the average time to resolution of 7.6 months, reported by Kim et al. in an earlier study. CONCLUSIONS De novo hydronephrosis after RALUR can be followed with serial renal ultrasounds. The majority of de novo hydronephrosis post-RALUR is transient and resolves spontaneously within a year of surgery with a very low re-intervention rate.
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12
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Olson P, Dudley AG, Rowe CK. Contemporary Management of Urinary Tract Infections in Children. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2022; 8:192-210. [PMID: 37521173 PMCID: PMC9108690 DOI: 10.1007/s40746-022-00242-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 10/29/2022]
Abstract
Purpose of Review Urinary tract infection (UTI) in children is a major source of office visits and healthcare expenditure. Research into the diagnosis, treatment, and prophylaxis of UTI has evolved over the past 10 years. The development of new imaging techniques and UTI screening tools has improved our diagnostic accuracy tremendously. Identifying who to treat is imperative as the increase in multi-drug-resistant organisms has emphasized the need for antibiotic stewardship. This review covers the contemporary management of children with UTI and the data-driven paradigm shifts that have been implemented into clinical practice. Recent Findings With recent data illustrating the self-limiting nature and low prevalence of clinically significant vesicoureteral reflux (VUR), investigational imaging in children has become increasingly less frequent. Contrast-enhanced voiding urosonogram (CEVUS) has emerged as a useful diagnostic tool, as it can provide accurate detection of VUR without the need of radiation. The urinary and intestinal microbiomes are being investigated as potential therapeutic drug targets, as children with recurrent UTIs have significant alterations in bacterial proliferation. Use of adjunctive corticosteroids in children with pyelonephritis may decrease the risk of renal scarring and progressive renal insufficiency. The development of a vaccine against an antigen present on Escherichia coli may change the way we treat children with recurrent UTIs. Summary The American Academy of Pediatrics defines a UTI as the presence of at least 50,000 CFU/mL of a single uropathogen obtained by bladder catheterization with a dipstick urinalysis positive for leukocyte esterase (LE) or WBC present on urine microscopy. UTIs are more common in females, with uncircumcised males having the highest risk in the first year of life. E. coli is the most frequently cultured organism in UTI diagnoses and multi-drug-resistant strains are becoming more common. Diagnosis should be confirmed with an uncontaminated urine specimen, obtained from mid-stream collection, bladder catheterization, or suprapubic aspiration. Patients meeting criteria for imaging should undergo a renal and bladder ultrasound, with further investigational imaging based on results of ultrasound or clinical history. Continuous antibiotic prophylaxis is controversial; however, evidence shows patients with high-grade VUR and bladder and bowel dysfunction retain the most benefit. Open surgical repair of reflux is the gold standard for patients who fail medical management with endoscopic approaches available for select populations.
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Affiliation(s)
- Philip Olson
- Department of Urology, University of Connecticut School of Medicine, 200 Academic Way, Farmington, CT 06032 USA
| | - Anne G. Dudley
- Division of Pediatric Urology, Connecticut Children’s, 282 Washington Street, Hartford, CT 06106 USA
| | - Courtney K. Rowe
- Division of Pediatric Urology, Connecticut Children’s, 282 Washington Street, Hartford, CT 06106 USA
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13
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Toni T, Lombardo A, Andolfi C, Gundeti MS. Ureteroneocystostomy without ureteral remodeling for grade III-V vesicoureteral reflux treatment. J Pediatr Urol 2021; 17:743.e1-743.e7. [PMID: 34364812 DOI: 10.1016/j.jpurol.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 07/06/2021] [Accepted: 07/09/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Ureteral remodeling (tapering or tailoring) is often performed alongside ureteroneocystostomy (ureteric reimplantation) procedures despite limited evidence on its role in promoting reflux resolution. OBJECTIVES To investigate the efficacy of ureteroneocystostomy in the absence of adjuvant ureteral remodeling for promoting reflux resolution in grade III-V vesicoureteral reflux. STUDY DESIGN A retrospective analysis identified pediatric patients who underwent open or robotic assisted ureteroneocystostomy (OUN and RAUN, respectively) without ureteral remodeling (tailoring or tapering) at a single tertiary care center. The primary endpoint of reflux resolution was defined as no reflux on latest follow up postoperative voiding cystourethrogram (VCUG). Ureteral dilation was analyzed using the ureteral diameter ratio (UDR), which normalized for image characteristics. Inclusion criteria was as follows: grade III-V reflux, accessible postoperative VCUG scan, RAUN after June 2013 following technique optimization, and no other structural urologic abnormality or associated neurogenic bladder. RESULTS A total of 68 ureters were analyzed (Grade III = 28, Grade IV = 27, Grade V = 13, OUN = 23, RAUN = 45). Complete reflux resolution was achieved postoperatively in 96% (27/28) of grade III, 100% (27/27) of grade IV and 100% (13/13) grade V cases, for a combined resolution rate of 99%. In the one failed case, the preoperative UDR was in the second quartile and postoperatively, reflux diminished from grade III to grade I. Notably, no cases with UDRs in the largest quartile required tapering/tailoring for complete reflux resolution. DISCUSSION Ureteral tapering and tailoring were unnecessary to achieve reflux resolution in grade III-V VUR by both OUN and RAUN. Additionally, the unsuccessful case was classified as grade III with a UDR value in the second quartile, suggesting that high grade reflux (IV-V) can be repaired without tapering with equal success rates to that of grade III VUR repair, which is classically not tapered. Tapering was unnecessary for complete reflux resolution in the cases with the largest ureteral diameter ratios (UDR). These findings are limited by the single center retrospective nature of the study. CONCLUSIONS This study demonstrates that vesicoureteral reimplantation for resolution of grade III-V reflux is successful in the absence of ureteral remodeling techniques.
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Affiliation(s)
- Tiffany Toni
- University of Chicago, Pritzker School of Medicine, Chicago, IL, USA.
| | - Alyssa Lombardo
- University of Chicago, Pritzker School of Medicine, Chicago, IL, USA.
| | - Ciro Andolfi
- University of Chicago, Department of Surgery, Section of Urology, Chicago, IL, USA.
| | - Mohan S Gundeti
- University of Chicago, Department of Surgery, Section of Urology, Chicago, IL, USA.
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14
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Esposito C, Castagnetti M, Autorino G, Coppola V, Cerulo M, Esposito G, Escolino M. Robot‑Assisted Laparoscopic Extra-Vesical Ureteral Reimplantation (Ralur/Revur) for Pediatric Vesicoureteral Reflux: A Systematic Review of Literature. Urology 2021; 156:e1-e11. [PMID: 34324913 DOI: 10.1016/j.urology.2021.06.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/05/2021] [Accepted: 06/30/2021] [Indexed: 11/29/2022]
Abstract
This literature review aimed to assess the outcomes of robot-assisted laparoscopic extra-vesical ureteral reimplantation (RALUR/REVUR) in standard, complex and re-operative cases. Twenty-two studies (period 2008-2019) containing 1362 children receiving RALUR/REVUR, were included. Unilateral repair was faster compared to bilateral (P = .0000). The overall patient success rate was 92%. The mean post-operative complications rate was 10.7%. The mean re-operations rate was 3.9%. The available data show that RALUR/REVUR can be a first line surgical approach for pediatric vesicoureteral reflux at most centers with the caveat that learning curves for the surgeons are expected as with most new surgical procedures.
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Affiliation(s)
- Ciro Esposito
- Division of Pediatric Surgery, Federico II University of Naples, Naples, Italy
| | - Marco Castagnetti
- Division of Pediatric Urology, Medical University of Padua, Padua, Italy
| | - Giuseppe Autorino
- Division of Pediatric Surgery, Federico II University of Naples, Naples, Italy
| | - Vincenzo Coppola
- Division of Pediatric Surgery, Federico II University of Naples, Naples, Italy
| | - Mariapina Cerulo
- Division of Pediatric Surgery, Federico II University of Naples, Naples, Italy
| | - Giorgia Esposito
- Division of Pediatric Surgery, Federico II University of Naples, Naples, Italy
| | - Maria Escolino
- Division of Pediatric Surgery, Federico II University of Naples, Naples, Italy.
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15
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Tyagi V, Pahwa M, Lodha P, Mistry T, Chadha S. Robot-assisted laparoscopic ureteral reimplant: A single-center experience. INDIAN JOURNAL OF UROLOGY : IJU : JOURNAL OF THE UROLOGICAL SOCIETY OF INDIA 2021; 37:42-47. [PMID: 33850354 PMCID: PMC8033243 DOI: 10.4103/iju.iju_185_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 08/27/2020] [Accepted: 10/11/2020] [Indexed: 11/19/2022]
Abstract
Introduction: Open ureteral reimplant has been the gold standard for management of lower ureteric strictures. With the widespread acceptance of robotic surgery, robotic-assisted laparoscopic ureteral reimplant (RALUR) is becoming the preferred choice for performing ureteral reimplant. We present our single-institution and single-surgeon experience of performing RALUR. Materials and Methods: We performed a retrospective analysis of 40 patients who underwent RALUR at our institute in the last 5 years. Demographic data were recorded along with presenting complaint and diagnosis. Intraoperative variables included operative and docking time, blood loss, intraoperative complications, technique, and procedure performed. Postoperative data that were analyzed included complications, hospital stay, and outcomes. Patient satisfaction score was calculated using a numerical scale of points 1–6. Results: The mean age of patients was 31.5 ± 9.8 years (r = 4–45). Male: female ratio was 3:5. The most common presenting symptom was flank pain, and the most common etiology was iatrogenic strictures in adults and congenital vesicoureteral reflux in children. The mean operative time and blood loss were 135.3 ± 45.1 min (r = 84–221) and 67.7 ± 31.4 ml (r = 32–118), respectively. There were no intraoperative complications and nil conversion to open surgery. The mean length of hospital stay was 4.5 ± 2.3 days (r = 3–9). Radiographic success was achieved in 41 out of 44 ureters. Eighty-five percent of the patients were completely satisfied with robotic approach and its outcomes. Conclusion: RALUR is a minimally invasive, safe, feasible, less morbid technique with good outcome.
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Affiliation(s)
- Vipin Tyagi
- Department of Urology, Sir Ganga Ram Hospital, New Delhi, India
| | - Mrinal Pahwa
- Department of Urology, Sir Ganga Ram Hospital, New Delhi, India
| | - Praveen Lodha
- Department of Urology, Sir Ganga Ram Hospital, New Delhi, India
| | - Tejas Mistry
- Department of Urology, Sir Ganga Ram Hospital, New Delhi, India
| | - Sudhir Chadha
- Department of Urology, Sir Ganga Ram Hospital, New Delhi, India
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16
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Läckgren G, Cooper CS, Neveus T, Kirsch AJ. Management of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years? Front Pediatr 2021; 9:650326. [PMID: 33869117 PMCID: PMC8044769 DOI: 10.3389/fped.2021.650326] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/05/2021] [Indexed: 12/12/2022] Open
Abstract
Vesicoureteral reflux (VUR) is associated with increased risks of urinary tract infection, renal scarring and reflux nephropathy. We review advancements over the last two decades in our understanding and management of VUR. Over time, the condition may resolve spontaneously but it can persist for many years and bladder/bowel dysfunction is often involved. Some factors that increase the likelihood of persistence (e.g., high grade) also increase the risk of renal scarring. Voiding cystourethrography (VCUG) is generally considered the definitive method for diagnosing VUR, and helpful in determining the need for treatment. However, this procedure causes distress and radiation exposure. Therefore, strategies to reduce clinicians' reliance upon VCUG (e.g., after a VUR treatment procedure) have been developed. There are several options for managing patients with VUR. Observation is suitable only for patients at low risk of renal injury. Antibiotic prophylaxis can reduce the incidence of UTIs, but drawbacks such as antibiotic resistance and incomplete adherence mean that this option is not viable for long-term use. Long-term studies of endoscopic injection have helped us understand factors influencing use and the effectiveness of this procedure. Ureteral reimplantation is still performed commonly, and robot-assisted laparoscopic methods are gaining popularity. Over the last 20 years, there has been a shift toward more conservative management of VUR with an individualized, risk-based approach. For continued treatment improvement, better identification of children at risk of renal scarring, robust evidence regarding the available interventions, and an improved VUR grading system are needed.
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Affiliation(s)
- Göran Läckgren
- Section of Urology, Department of Pediatric Surgery, University Children's Hospital, Uppsala, Sweden
| | | | - Tryggve Neveus
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Andrew J Kirsch
- Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, United States
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17
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Bastos JM, Rondon AV, Machado MG, Zerati M, Nascimento RLP, Lima SVC, Calado ADA, Barroso U. Brazilian consensus on vesicoureteral reflux-recommendations for clinical practice. Int Braz J Urol 2020; 46:523-537. [PMID: 32167732 PMCID: PMC7239285 DOI: 10.1590/s1677-5538.ibju.2019.0401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/01/2019] [Indexed: 12/11/2022] Open
Abstract
Introduction Vesicoureteral Reflux (VUR) is characterized by a retrograde flow of urine from the bladder into the ureters and kidneys. It is one of the most common urinary tract anomalies and the major cause of urinary tract infection (UTI) in the first years of life. If not properly diagnosed and treated can lead to recurrent UTI, renal scar and, in severe cases, to end stage renal disease. Despite recent advances in scientific and technological knowledge, evaluation and treatment of VUR is still controversial and there is still considerable heterogeneity in evaluation methods and therapeutic approaches. The aim of the present consensus is to give a practical orientation on how to evaluate and treat VUR. Methods The board of Pediatric Urology of the Brazilian Society of Urology joined a group of experts and reviewed all important issues on Vesicoureteral Reflux evaluation and treatment and elaborated a draft of the document. On November 2017 the panel met to review, discuss and write a consensus document. Results and Discussion Vesicoureteral Reflux is a common and challenging problem in children. Children presenting with Vesicoureteral Reflux require careful evaluation and treatment to avoid future urinary tract infections and kidney scars. The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies.
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Affiliation(s)
- José Murillo Bastos
- Universidade Federal de Juiz de Fora -UFJF, Juiz de Fora, MG, Brasil.,Hospital e Maternidade Therezinha de Jesus da Faculdade de Ciências Médicas e Saúde de Juiz de Fora - HMTJ-SUPREMA, Juiz de Fora, MG, Brasil
| | - Atila Victal Rondon
- Universidade do Estado do Rio de Janeiro - UERJ, Rio de Janeiro, RJ, Brasil.,Hospital Federal Cardoso Fontes - HFCF, Rio de Janeiro, RJ, Brasil
| | | | - Miguel Zerati
- Instituto de Urologia e Nefrologia de São José do Rio Preto - IUN, S J do Rio Preto, SP, Brasil
| | | | | | - Adriano de Almeida Calado
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo - HCFMRP-USP, Ribeirão Preto, SP, Brasil
| | - Ubirajara Barroso
- Universidade Federal da Bahia - UFBA, Salvador, BA, Brasil.,Escola Bahiana de Medicina - BAHIANA, Salvador, BA, Brasil
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18
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Mittal S, Srinivasan A, Bowen D, Fischer KM, Shah J, Weiss DA, Long CJ, Shukla AR. Utilization of Robot-assisted Surgery for the Treatment of Primary Obstructed Megaureters in Children. Urology 2020; 149:216-221. [PMID: 33129867 DOI: 10.1016/j.urology.2020.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 10/05/2020] [Accepted: 10/08/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To describe the technical aspects of robot assisted laparoscopic ureteral reimplantation (RALUR) for the management of primary obstructive megaureter (POM) and report initial outcomes, safety, and feasibility of the procedure. METHODS Using an IRB- approved robotic surgery registry, we performed a retrospective chart review of patients undergoing RALUR for POM between April 2009 and May 2019. RESULTS A total of 18 patients underwent RALUR using a modified Lich-Gregoir technique for management of POM and 7 (38.9%) of these underwent intracorporeal ureteral tapering at the time of surgery. At median follow up of 27.5 (IQR 11-50) months, no patient required reoperation for recurrent obstruction and all patients had improvement in hydronephrosis postoperatively. 30-day complications were low with 1 Grade I, 2 Grade II and 1 Grade III Clavien-Dindo complication. The most common issue postoperatively was febrile urinary tract infection, occurring in 6 patients (33.3%), at an average of 3.2 months after surgery. Increased operative time was the only significant difference between the tapered verses nontapered group. CONCLUSION We present the largest series of RALUR for POM to date. Based upon our initial experience with this technique we believe it is technically feasible and reproducible with good outcomes and low complication rates. Future studies are needed to track long-term outcomes and better understand indications for and the utility of ureteral tapering as well as how to minimize febrile UTIs postoperatively. Additional follow up is needed to determine the efficacy of RALUR as compared to open ureteral reimplantation for POM.
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Affiliation(s)
- Sameer Mittal
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3(rd) Floor West Pavilion, Philadelphia, PA.
| | - Arun Srinivasan
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3(rd) Floor West Pavilion, Philadelphia, PA
| | - Diana Bowen
- Department of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL
| | - Katherine M Fischer
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3(rd) Floor West Pavilion, Philadelphia, PA
| | - Jay Shah
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA
| | - Dana A Weiss
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3(rd) Floor West Pavilion, Philadelphia, PA
| | - Christopher J Long
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3(rd) Floor West Pavilion, Philadelphia, PA
| | - Aseem R Shukla
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3(rd) Floor West Pavilion, Philadelphia, PA
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19
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Rappaport YH, Kord E, Noh PH, Koucherov S, Gaber J, Shumaker A, Zisman A, Stav K, Chertin B, Dubrov V, Bondarenko S, Neheman A. Minimally Invasive Dismembered Extravesical Cross-Trigonal Ureteral Reimplantation for Obstructed Megaureter: A Multi-Institutional Study Comparing Robotic and Laparoscopic Approaches. Urology 2020; 149:211-215. [PMID: 33122054 DOI: 10.1016/j.urology.2020.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/04/2020] [Accepted: 10/13/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare 2 minimally invasive surgical options for the treatment of obstructed megaureter: robot assisted dismembered extravesical cross-trigonal ureteral reimplantation (RADECUR) and laparoscopic dismembered extravesical cross-trigonal ureteral reimplantation (LDECUR). METHODS A 2 arm retrospective comparative study, including all pediatric patients who underwent ureteral reimplantation of unilateral obstructed megaureter, either by RADECUR or LDECUR. Patient demographics, perioperative surgical data, complications, and results are described. The surgical technique in both arms was similar: dismembering of the ureter, performing an extravesical cross-trigonal detrusorotomy, and intracorporeal tailoring of the ureter when indicated, were the pivotal maneuvers utilized. RESULTS The study included 95 patients (48 and 47 in the RADECUR and LDECUR arms, respectively) operated between the years 2016 and 2019. Overall, median age at surgery was 24 months (IQR 12-48) and median weight was 14 kg (IQR 11-21). Median operative time was 93 minutes (IQR 90-120) for RADECUR and 130 minutes (IQR 105-160) for LDECUR (P< 0.001). Intracorporeal excisional tapering was performed in 11 of the RADECUR patients and 19 LDECUR patients. Grade 1-2 Clavien-Dindo complications occurred in 7 patients, and grade 3 complication in 1 patient in the RADECUR arm. In the LDECUR arm, grade 1-2 complications occurred in 2 patients, and 2 had a grade 3 complications. Surgical success was achieved in 97% and 94% in the RADECUR and LDECUR groups, respectively. CONCLUSION Unilateral robotic extravesical cross-trigonal ureteral re-implantation for treatment of obstructed megaureter in the pediatric population is safe and effective both for RADECUR and LDECUR. Operative time is significantly shorter for RADECUR.
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Affiliation(s)
| | - Eyal Kord
- Department of Urology, Shamir Medical Center, Zerifin, Israel
| | - Paul H Noh
- University Urology, 3290 Dauphin Street, Mobile, AL
| | - Stanislav Koucherov
- Departments of Urology & Pediatric Urology, Shaare Zedek Medical Center; Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Jaudat Gaber
- Departments of Urology & Pediatric Urology, Shaare Zedek Medical Center; Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Andrew Shumaker
- Department of Urology, Shamir Medical Center, Zerifin, Israel
| | - Amnon Zisman
- Department of Urology, Shamir Medical Center, Zerifin, Israel
| | - Kobi Stav
- Department of Urology, Shamir Medical Center, Zerifin, Israel
| | - Boris Chertin
- Departments of Urology & Pediatric Urology, Shaare Zedek Medical Center; Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Vitaly Dubrov
- Department of Pediatric Urology, Children's City Clinical Hospital, Minsk, Republic of Belarus
| | - Sergey Bondarenko
- Department of Pediatric Urology, Municipal Hospital, Volgograd, Russia
| | - Amos Neheman
- Department of Urology, Shamir Medical Center, Zerifin, Israel
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Zhang P, Shi T, Fam X, Gu L, Xuan Y, Yang L, Wang B, Ai X, Jia Z, Li H, Zhang X, Ma X. Robotic-assisted laparoscopic pyeloplasty as management for recurrent ureteropelvic junction obstruction: a comparison study with primary pyeloplasty. Transl Androl Urol 2020; 9:1278-1285. [PMID: 32676411 PMCID: PMC7354308 DOI: 10.21037/tau.2020.03.25] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background To analyze the perioperative parameters and outcomes of robotic-assisted laparoscopic pyeloplasty (RALP) for recurrent ureteropelvic junction obstruction (UPJO) and compare them with our series of RALP for primary UPJO. Secondary pyeloplasty can be a challenging procedure because of ureteral devascularization, fibrosis and dense stricture formation. Robotic approach could be adjunct to these repairs. Methods Between August 2015 to March 2019, 96 patients in our hospital underwent RALP, with 32 patients as secondary intervention for recurrent UPJO. We compared the perioperative parameters of RALP for both primary UPJO and recurrent UPJO. Patient demographics, perioperative parameters, postoperative outcomes and complications from both groups were analyzed and compared. Results RALP was successfully performed for all cases in both groups. The median operating time was longer for secondary RALP than for primary RALP [125 (108.5–155) vs. 151 (120–190) minutes, P=0.004]. There were no conversions to open surgery or significant perioperative complications. No difference in blood loss, transfusion rate and perioperative complication rates was noted between the two groups. The success rates were 98.44% (63/64) and 96.88% (31/32) at a median follow up of 32 and 20 months (P=0.001) for the primary and secondary groups, respectively. Conclusions Secondary RALP is associated with significantly longer operative time as compared to primary RALP, especially during the exposure of the UPJO, however it is a safe surgical modality for recurrent UPJO with durable outcome. RALP should be an alternative treatment modality for recurrent UPJO whenever the facility and expert are available.
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Affiliation(s)
- Peng Zhang
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing 100853, China
| | - Taoping Shi
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing 100853, China
| | - Xenginn Fam
- Urology Unit, Department of Surgery, UKM Medical Centre, Kuala Lumpur, Malaysia
| | - Liangyou Gu
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing 100853, China
| | - Yundong Xuan
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing 100853, China
| | - Luojia Yang
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing 100853, China
| | - Baojun Wang
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing 100853, China
| | - Xing Ai
- Department of Urology, PLA Army General Hospital, Beijing 100853, China
| | - Zhuomin Jia
- Department of Urology, PLA Army General Hospital, Beijing 100853, China
| | - Hongzhao Li
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing 100853, China
| | - Xu Zhang
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing 100853, China
| | - Xin Ma
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing 100853, China
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Aydin C, Akkoc A, Topaktas R, Senturk AB, Aydin ZB, Ürkmez A, Yaytokgil M. Comparison of Cohen and Lich-Gregoir ureteral reimplantation in the surgical management of primary unilateral vesicoureteral reflux in children. ACTA ACUST UNITED AC 2020; 66:424-429. [PMID: 32578774 DOI: 10.1590/1806-9282.66.4.424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 11/10/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Vesicoureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. Various intravesical and extravesical techniques have been described for the surgical correction of VUR. The aim of our study was to compare the results of open intravesical and extravesical procedures for unilateral primary VUR in children. METHODS Between January 2012 and August 2018, 38 children with primary VUR who underwent open ureteral reimplantation surgery were retrospectively reviewed. The Cohen (intravesical) and the Lich-Gregoir (extravesical) approach were grouped as groups A and B, respectively. The groups were compared for age, gender, preoperative reflux grade, presence of lower urinary tract symptoms, operation time, discomfort and pain, analgesic requirements, duration of hematuria, postoperative complications, and hospital stay. All the parameters were statistically compared. RESULTS There were 38 patients in this study. Group A had 18 patients, and group B had 20 patients. The mean operative time was significantly shorter in group B than in group A. The mean hospital stay was also shorter in group B. The urethral foley stay period was 4.7±0.9 days 2±0 days (p = 0.000*), respectively, for group A and B. Macroscopic hematuria was seen in group A. The objective pain scale was worse after intravesical surgery. Analgesic requirements were higher in group A (p =0.131). CONCLUSION Intravesical and extravesical ureteroneocystostomy methods are equally successful and feasible in the treatment of primary unilateral VUR. The Cohen technique is associated with a longer and more painful hospital stay, gross hematuria, and longer operative time, compared to the Lich-Gregoir technique.
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Affiliation(s)
- Cemil Aydin
- . Department of Urology, Hitit University School of Medicine, Training and Research Hospital, Corum, Turkey
| | - Ali Akkoc
- . Department of Urology, Alaaddin Keykubat University School of Medicine, Training and Research Hospital, Alanya, Turkey
| | - Ramazan Topaktas
- . Department of Urology, Haydarpaşa Numune Training and Research Hospital, İstanbul, Turkey
| | - Aykut Bugra Senturk
- . Department of Urology, Hitit University School of Medicine, Training and Research Hospital, Corum, Turkey
| | - Zeynep Banu Aydin
- . Department of Radiology, Hitit University School of Medicine, Training and Research Hospital, Corum, Turkey
| | - Ahmet Ürkmez
- . Department of Urology, Haydarpaşa Numune Training and Research Hospital, İstanbul, Turkey
| | - Muhammet Yaytokgil
- . Department of Urology, Hitit University School of Medicine, Training and Research Hospital, Corum, Turkey
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Abstract
Minimally invasive techniques have gained popularity in pediatric surgery. Among these, is the robotic approach for ureteral reimplantation in children with vesico-ureteral reflux. We describe main indications of this surgery, our surgical technique as well as trouble shooting of anatomical variants and the post-operative management. We also provide a description of other techniques described in the literature and a brief review of outcomes of published series.
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Affiliation(s)
- Niccolo Passoni
- Pediatric Urology, Children's Health Texas, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Craig A Peters
- Pediatric Urology, Children's Health Texas, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Esposito C, Varlet F, Riquelme MA, Fourcade L, Valla JS, Ballouhey Q, Scalabre A, Escolino M. Postoperative bladder dysfunction and outcomes after minimally invasive extravesical ureteric reimplantation in children using a laparoscopic and a robot-assisted approach: results of a multicentre international survey. BJU Int 2019; 124:820-827. [DOI: 10.1111/bju.14785] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Ciro Esposito
- Division of Pediatric Surgery and Urology; Federico II University of Naples; Naples Italy
| | - Francois Varlet
- Division of Pediatric Surgery; CHU de Saint-Etienne; Saint-Etienne France
| | - Mario A. Riquelme
- Division of Pediatric Surgery; Christus-Muguerza Hospital; Monterrey Mexico
| | - Laurent Fourcade
- Division of Pediatric Surgery; CHU de Limoges; Hopital de la Mère et de l'Enfant; Limoges France
| | - Jean S. Valla
- Division of Pediatric Surgery; CHU Lenval; Nice France
| | - Quentin Ballouhey
- Division of Pediatric Surgery; CHU de Limoges; Hopital de la Mère et de l'Enfant; Limoges France
| | - Aurelien Scalabre
- Division of Pediatric Surgery; CHU de Saint-Etienne; Saint-Etienne France
| | - Maria Escolino
- Division of Pediatric Surgery and Urology; Federico II University of Naples; Naples Italy
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24
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Abstract
Current management of vesicoureteral reflux (VUR) in children is the result of a steady albeit controversial evolution of data and thinking related to the clinical impact of VUR and urinary tract infection (UTI) in children, the value of clinical screening, and the relative impact of testing and interventions for VUR. While controversy continues, there is consensus on the importance of bladder dysfunction on VUR outcomes, the likelihood of VUR resolution, and the fact that not all children with VUR require active treatment. Early efforts to define risk stratification hold the most promise to provide more patient-specific treatment of UTI and VUR in children.
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Affiliation(s)
- Angelena Edwards
- Children's Health System Texas, University of Texas Southwestern, Dallas, TX, USA
| | - Craig A Peters
- Children's Health System Texas, University of Texas Southwestern, Dallas, TX, USA
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25
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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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Sahadev R, Spencer K, Srinivasan AK, Long CJ, Shukla AR. The Robot-Assisted Extravesical Anti-reflux Surgery: How We Overcame the Learning Curve. Front Pediatr 2019; 7:93. [PMID: 30984718 PMCID: PMC6450052 DOI: 10.3389/fped.2019.00093] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Accepted: 03/04/2019] [Indexed: 02/03/2023] Open
Abstract
Management of vesicoureteral reflux (VUR) has evolved over the past several decades, with a trend toward a decrease in surgical management. In spite of this, ureteral reimplantation remains a commonly performed procedure by pediatric urologists in selected cases. Although the basic tenets of the ureteral reimplant procedure remain the same, the extra- vs. intravesical approach, and the traditional open vs. minimally invasive approach remain the primary options to correct reflux. Considering the advantages conferred by the robotic surgery platform, many leading centers have preferentially adopted robot-assisted laparoscopic extravesical anti-reflux surgery, or in common surgical parlance, the robot-assisted laparoscopic ureteral reimplantation (RALUR), over pure laparoscopic or open approaches. Predicated on our experience of performing over 170 cases of RALUR, we have made technical modifications which we posit reduce the morbidity of the procedure while offering acceptable outcomes. This review highlights the evolution and establishment of RALUR as a standardization of care in the surgical management of VUR at our institution. In particular, we emphasize the technical nuances and specific challenges encountered through the learning curve in hopes of facilitating this process for others.
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Affiliation(s)
- Ravindra Sahadev
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Katelyn Spencer
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Arun K Srinivasan
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Christopher J Long
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Aseem Ravindra Shukla
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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27
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Bilgutay AN, Kirsch AJ. Robotic Ureteral Reconstruction in the Pediatric Population. Front Pediatr 2019; 7:85. [PMID: 30968006 PMCID: PMC6439422 DOI: 10.3389/fped.2019.00085] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 02/27/2019] [Indexed: 12/17/2022] Open
Abstract
Robot-assisted laparoscopic (RAL) surgery is a safe, minimally invasive technique that has become more widely used in pediatric urology over recent decades. With several advantages over standard laparoscopy, robotic surgery is particularly well-suited to reconstructive surgery involving delicate structures like the ureter. A robotic approach provides excellent access to and visualization of the ureter at all levels. Common applications include upper ureteral reconstruction (e.g., pyeloplasty, ureteropelvic junction polypectomy, ureterocalicostomy, and high uretero-ureterostomy in duplex systems), mid-ureteral reconstruction (e.g., mid uretero-ureterostomy for stricture or polyp), and lower ureteral reconstruction (e.g., ureteral reimplantation and lower ureter-ureterostomy in duplex systems). Herein, we describe each of these robotic procedures in detail.
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Affiliation(s)
- Aylin N Bilgutay
- Department of Pediatric Urology, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Andrew J Kirsch
- Department of Pediatric Urology, Children's Healthcare of Atlanta, Atlanta, GA, United States.,Department of Urology, Emory University School of Medicine, Atlanta, GA, United States
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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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Current status of robotic-assisted surgery for the treatment of vesicoureteral reflux in children. Curr Opin Urol 2018; 27:20-26. [PMID: 27764016 DOI: 10.1097/mou.0000000000000357] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Although open ureteral reimplantation remains the gold standard for surgical correction of vesicoureteral reflux (VUR), robotic-assisted laparoscopic ureteral reimplantation (RALUR) holds promise and is becoming more widely utilized. The present article outlines primary operative techniques for RALUR, summarizes the current literature with respect to surgical outcomes and costs, and discusses early applications of RALUR to complex and reoperative cases. RECENT FINDINGS Intravesical and extravesical techniques for RALUR have been described. Published outcomes vary with respect to operational definitions of surgical success and reporting of complications. Several studies have directly compared RALUR and open reimplant, suggesting equivalent efficacy and safety. Recent noncomparative studies have reported lower VUR resolution rates and higher complication rates for RALUR, particularly in bilateral cases. The application of RALUR to reoperative surgery and cases requiring tapering and dismemberment is under very early investigation. RALUR is consistently associated with lower postoperative analgesic requirements and decreased hospital stay, but longer operative times and higher costs compared to open reimplant. SUMMARY Published outcomes after RALUR show mixed results that, on average, may be inferior to open reimplant. Future investigations should seek to identify patient-related and intraoperative factors associated with successful and unsuccessful outcomes.
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Silay MS, Turan T, Kayalı Y, Başıbüyük İ, Gunaydin B, Caskurlu T, Karaman Mİ. Comparison of intravesical (Cohen) and extravesical (Lich-Gregoir) ureteroneocystostomy in the treatment of unilateral primary vesicoureteric reflux in children. J Pediatr Urol 2018; 14:65.e1-65.e4. [PMID: 29146303 DOI: 10.1016/j.jpurol.2017.09.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 09/22/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Various intravesical and extravesical techniques have been described for the surgical correction of vesicoureteral reflux (VUR). Among those techniques Cohen (intra-vesical) and Lich-Gregoir (extra-vesical) are the most commonly used ones. However, there are limited studies that compare those two surgical techniques in the literature. OBJECTIVE In this study, we aim to compare the outcomes of the open intravesical and extravesical procedures for unilateral primary VUR in children. METHODS We analyzed the records of 118 consecutive children with primary VUR who underwent open ureteral reimplantation surgery by single surgeon from January 2011 to October 2015 at our institution. Among them, intravesical reimplantation was group A, and extravesical reimplantation procedure was group B. We retrospectively analyzed the clinical data of both groups, including age, sex, preoperative reflux grade, presence of lower urinary tract symptoms (LUTS), operative time, postoperative complications and hospitalization period. Success of surgery was defined as the resolution of the VUR as determined by voiding cystourethrography 6 -12 months after surgery. All the parameters were statistically compared. RESULTS A total of 58 patients were found eligible for the study. In 23 cases intravesical (group A) and in 35 cases extravesical (group B) procedure were performed. The operative time in group A was significantly higher than group B (110.3±16.9 and 87±29.8 min, respectively, p = 0.002). The mean hospital stay was also longer in group A (2.8±0.8 and 1.2±0.6 days, respectively, p = 0.007). The ureteral catheterization periods were 14.1±6.1 days for group A and there was no ureteral catheter placement in group B. The success rate of the two groups were comparable (100% vs 94.9%, p = 0.513). No intraoperative complications were detected in either group. The number of febrile urinary tract infections were similar between the groups after a mean follow up of 18.2 months (p = 0.746). DISCUSSION Our results confirmed that both Cohen and Lich-Gregoir procedures had equivalent success and complication rates. Lich-Gregoir technique was found superior to Cohen technique in terms of hospital stay and operative time. Moreover, it avoids the necessity of urethral and ureteral stenting which probably might increase the comfort of the patients postoperatively. The main limitations of our study are unrecorded pain scores and amount of analgesics taken the after surgery and retrospective analysis of the data. CONCLUSION Both the open intravesical and extravesical ureteroneocystostomy procedures are equally effective in the treatment of primary unilateral VUR. Any of the techniques can be opted by the surgeons depending on their surgical experience.
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Affiliation(s)
- Mesrur Selcuk Silay
- Istanbul Medeniyet University, Faculty of Medicine, Department of Urology, Istanbul, Turkey.
| | - Turgay Turan
- Istanbul Medeniyet University, Faculty of Medicine, Department of Urology, Istanbul, Turkey
| | - Yunus Kayalı
- Istanbul Medeniyet University, Faculty of Medicine, Department of Urology, Istanbul, Turkey
| | - İsmail Başıbüyük
- Istanbul Medeniyet University, Faculty of Medicine, Department of Urology, Istanbul, Turkey
| | - Bilal Gunaydin
- Istanbul Medeniyet University, Faculty of Medicine, Department of Urology, Istanbul, Turkey
| | - Turhan Caskurlu
- Istanbul Medeniyet University, Faculty of Medicine, Department of Urology, Istanbul, Turkey
| | - M İhsan Karaman
- Istanbul Medeniyet University, Faculty of Medicine, Department of Urology, Istanbul, Turkey
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Robot-assisted laparoscopic versus open ureteral reimplantation for pediatric vesicoureteral reflux: a systematic review and meta-analysis. World J Urol 2018; 36:819-828. [PMID: 29374841 DOI: 10.1007/s00345-018-2194-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 01/19/2018] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To compare the efficacy and safety of robot-assisted laparoscopic ureteral reimplantation (RALUR) and open ureteral reimplantation (OUR) in treating primary pediatric vesicoureteral reflux (VUR) based on published literature. METHODS A comprehensive literature search of PubMed, Embase, Cochrane Library, CBM, CNKI and VIP databases was conducted to identify studies comparing the outcomes of RALUR with OUR for treating primary pediatric VUR. The last search was in January 2017. Summarized mean differences (MDs) or odds ratios (ORs) with 95% confidence intervals (CIs) were used to assess the differences in outcomes between RALUR and OUR. RESULTS A total of six studies containing 7122 children with primary VUR were included in this analysis. Significantly longer operation time was needed for RALUR than OUR (MD 66.69 min, 95% CI 41.71-91.67, P < 0.00001), while the RALUR group had significantly fewer days of hospital stay (MD - 17.80 h, 95% CI - 21.18 to - 14.42, P < 0.00001) and postoperative Foley placement (MD - 0.32 days, 95% CI - 0.57 to - 0.07, P = 0.01). No significant differences were found in estimated blood loss during operation, success rate, complications, and postoperative analgesia usage between the two groups. In subgroup analyses, a significantly higher rate of short-term postoperative complications in RALUR was found compared with OUR (OR 3.17, 95% CI 1.72-5.85, P = 0.0002). CONCLUSIONS Our study indicates that compared with OUR, RALUR is also an effective surgical approach for primary pediatric VUR and could help patients return to society more quickly; however, short-term postoperative complications of RALUR should be considered cautiously.
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Horasanli K, Bayar G, Acinikli H, Kutsal C, Kirecci SL, Dalkilic A. Lower urinary tract dysfunction in pediatric patients after ureteroneocystostomy due to vesicoureteral reflux: Long-term follow-up. Low Urin Tract Symptoms 2018; 11:O48-O52. [PMID: 29322636 DOI: 10.1111/luts.12213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 10/26/2017] [Accepted: 11/14/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The aim of the present study was to evaluate long-term lower urinary tract dysfunction (LUTD) in pediatric patients who underwent ureteroneocystostomy due to vesicoureteral reflux. METHODS The present retrospective study was performed on 61 patients. Patients were divided into 3 groups: Group 1 (n = 26), did not have LUTD; Group 2 (n = 23), had LUTD; and Group 3 (n = 12), was not toilet trained preoperatively. Patients were reassessed regarding de novo LUTD or the persistence of LUTD at least 7 years after the ureteroneocystostomy. RESULTS Mean patient age was 7 years (range 1-15) when ureteroneocystostomy was performed and the surgery was associated with a 92% success rate. The mean follow-up period was 10 years (range 7-12 years). Postoperative LUTD was present in 6 (23%), 12 (52%), and 1 (8.3%) patients in Groups 1, 2, and 3, respectively. The presence of LUTD before surgery and bilateral repair in the same setting were predictive risk factors for the presence of LUTD during the long-term follow-up. LUTD occurred at higher rate in Group 2 than in Groups 1 and 3 (52% vs. 23% and 8.3%, respectively; P = .015). The presence of de novo LUTD was significant in Group 1 compared with the presence of preoperative and postoperative LUTD (P = .031, Wilcoxon analysis). CONCLUSIONS LUTD may not resolve after a ureteroneocystostomy, and additional therapy could be necessary. Due to the probability of damage to the ureterovesical nerve and/or disturbed bladder dynamics, de novo LUTD may occur in patients with bilateral high-grade reflux without LUTD before a ureteroneocystostomy.
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Affiliation(s)
- Kaya Horasanli
- Urology Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Göksel Bayar
- Urology Department, Idil State Hospital, Sirnak, Turkey
| | | | - Cemil Kutsal
- Urology Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Sinan L Kirecci
- Urology Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Ayhan Dalkilic
- Urology Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
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Babbar P, Yerram N, Sun A, Hemal S, Murthy P, Bryk D, Nandanan N, Nyame Y, Caveney M, Nelson R, Berglund R. Robot-assisted ureteral reconstruction - current status and future directions. Urol Ann 2018; 10:7-14. [PMID: 29416268 PMCID: PMC5791461 DOI: 10.4103/ua.ua_94_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Robotic surgery in the treatment in certain urological diseases has become a mainstay. With the increasing use of the robotic platform, some surgeries which were historically performed open have transitioned to a minimally invasive technique. Recently, the robotic approach has become more utilized for ureteral reconstruction. In this article, the authors review the surgical techniques for a number of major ureteral reconstuctive surgeries and briefly discuss the outcomes reported in the literature.
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Affiliation(s)
- Paurush Babbar
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
| | - Nitin Yerram
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
| | - Andrew Sun
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
| | - Sij Hemal
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
| | - Prithvi Murthy
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
| | - Darren Bryk
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
| | - Naveen Nandanan
- Division of Urology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Yaw Nyame
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
| | - Maxx Caveney
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
| | - Ryan Nelson
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
| | - Ryan Berglund
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
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Robot-assisted extravesical ureteral reimplantation (revur) for unilateral vesico-ureteral reflux in children: results of a multicentric international survey. World J Urol 2017; 36:481-488. [PMID: 29248949 DOI: 10.1007/s00345-017-2155-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 12/10/2017] [Indexed: 12/14/2022] Open
Abstract
PURPOSE This multicentric international retrospective study aimed to report the outcome of robot-assisted extravesical ureteral reimplantation (REVUR) in patients with unilateral vesico-ureteral reflux (VUR). METHODS The medical records of 55 patients (35 girls, 20 boys) underwent REVUR in four international centers of pediatric robotic surgery for primary unilateral VUR were retrospectively reviewed. Patients' average age was 4.9 years. The preoperative grade of reflux was III in 12.7%, IV in 47.3% and V in 40%. Twenty-six patients (47.3%) presented a loss of renal function preoperatively and 10 (18.1%) had a duplex system. RESULTS Average robot docking time was 16.2 min (range 5-30). Average total operative time was 92.2 min (range 50-170). No conversions or intra-operative complications were recorded. All patients had a bladder Foley catheter for 24 h post-operatively. Average hospital stay was 2 days (range 1-3). Average follow-up length was 28 months (range 9-60). We recorded three (5.4%) postoperative complications: 1 small urinoma resolved spontaneously (II Clavien) and 2 persistent reflux, only one requiring redo-surgery using endoscopic injection (IIIb Clavien). CONCLUSION REVUR is a safe and effective technique for treatment of primary unilateral VUR. The procedure is easy and fast to perform thanks to the 6° of freedom of robotic arms. The learning curve is short and it is useful to begin the robotics experience with a surgeon expert in robotic surgery as proctor on the 2nd robot console. The high cost and the diameter of instruments remain the main challenges of robotics applications in pediatric urology.
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Garcia-Roig M, Travers C, McCracken CE, Kirsch AJ. National Trends in the Management of Primary Vesicoureteral Reflux in Children. J Urol 2017; 199:287-293. [PMID: 28941917 DOI: 10.1016/j.juro.2017.09.073] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE In September 2011 the AAP (American Academy of Pediatrics) released updated guidelines for the evaluation of children 2 to 24 months old with a febrile urinary tract infection. We documented the impact of the guideline on diagnosis and surgical management of vesicoureteral reflux at U.S. children's hospitals. We hypothesized that voiding cystourethrogram studies and the vesicoureteral reflux treatment rate decreased concurrent with the national guideline release. MATERIALS AND METHODS The Pediatric Health Information System was queried for children (younger than 18 years) with primary vesicoureteral reflux and their antireflux surgical history from January 2004 to June 2015. Voiding cystourethrogram orders were recorded. Interrupted time series analysis quantified trends surrounding several seminal vesicoureteral reflux publications (2007) and guideline publication (2011). RESULTS A total of 43,341 voiding cystourethrogram encounters (male 23,946 [55.3%]) were identified for patients at a median age of 3 months (IQR 1-20). For all children monthly voiding cystourethrogram orders increased (+1.0 to +1.6 encounters per month, p <0.034) to September 2011, then sharply declined by 106 encounters per month from September to October 2011 (p <0.001) then did not change significantly (p=0.096, R2=0.79). For those children 2 to 24 months old with a urinary tract infection (3,379 records; male 1,384 [41.0%], median age 4 months [IQR 3-7]) voiding cystourethrograms gradually increased from January 2007 to September 2011 (+0.1 encounters per month, p=0.036), then similarly decreased by 21 encounters per month from September to October 2011 (p <0.001), then did not change significantly (p=0.064, R2=0.78). Overall 28,484 procedures for primary vesicoureteral reflux were identified (male 5,950 [20.9%], median age 4.8 years [IQR 2.5-7.2]). Total surgical procedures did not change significantly until October 2011, then declined (-1.5 procedures per month, p <0.001, R2=0.66). CONCLUSIONS The number of voiding cystourethrograms ordered nationally in all children and those with a urinary tract infection decreased sharply with the 2011 AAP urinary tract infection guideline release and did not change thereafter. A steady decline in procedures for primary vesicoureteral reflux occurred after October 2011.
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Affiliation(s)
- Michael Garcia-Roig
- Department of Pediatric Urology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Curtis Travers
- Department of Pediatrics - Biostatistics Core, Emory University, Atlanta, Georgia
| | - Courtney E McCracken
- Department of Pediatrics - Biostatistics Core, Emory University, Atlanta, Georgia
| | - Andrew J Kirsch
- Department of Pediatric Urology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia.
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Hajiyev P, Burgu B. Contemporary Management of Vesicoureteral Reflux. Eur Urol Focus 2017; 3:181-188. [PMID: 28918954 DOI: 10.1016/j.euf.2017.08.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 08/31/2017] [Indexed: 02/08/2023]
Abstract
CONTEXT Vesicoureteral reflux (VUR) remains the most interesting topic of pediatric urology due to the dynamic nature of recent controversial publications. Starting from the need for a diagnosis to the necessity and effectiveness of treatment in preventing scars, VUR remains in the mist. Although recent strong evidence helped as fog lights in this blurriness, more data are required for achieving crystal clearance. This article aims to summarize and discuss the current state of the evidence regarding VUR management. OBJECTIVE To provide a comprehensive synthesis of the main evidence in the literature on the current and contemporary management of VUR in children; to discuss conservative management with continuous antibiotic prophylaxis (CAP), especially its effectiveness and safety; and to review the current evidence regarding contemporary surgical techniques. EVIDENCE ACQUISITION We conducted a nonsystematic review of the literature using the recent guidelines and PubMed database regarding surveillance, CAP, endoscopic, open, laparoscopic, and robot-assisted ureteral surgical treatment. EVIDENCE SYNTHESIS Despite the striking results of previous studies revealing the ineffectiveness of CAP, more recent studies and their two fresh meta-analyses revealed a positive role for CAP in the contemporary management of VUR. One of the most interesting findings is the redundant rising of endoscopic correction and its final settlement to real indicated cases. Patient individualization in the contemporary management of VUR seems to be the keyword. The evidence in the literature showed a safe and effective use of laparoscopic and robot-assisted laparoscopic reimplantations. CONCLUSIONS The goal of VUR treatment is to prevent the occurrence of febrile urinary tract infections and formation of scars in the renal parenchyma. The approach should be risk adapted and individualized according to current knowledge. Individual risk is influenced by the presentation age, sex, history of pyelonephritis and renal damage, grade of reflux, bladder bowel dysfunction, and circumcision status. PATIENT SUMMARY Vesicoureteral reflux is a nonphysiological reflux of urine from the bladder through the ureters to the kidney. Treatment depends on the presentation of the vesicoureteral reflux (VUR). Therapeutic options range from watchful waiting to open surgery. This article aims to summarize and discuss the current state of the evidence regarding VUR management.
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Affiliation(s)
- Perviz Hajiyev
- Department of Pediatric Urology, Ankara University School of Medicine, Cebeci Children's Hospital, Ankara, Turkey.
| | - Berk Burgu
- Department of Pediatric Urology, Ankara University School of Medicine, Cebeci Children's Hospital, Ankara, Turkey
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Boysen WR, Ellison JS, Kim C, Koh CJ, Noh P, Whittam B, Palmer B, Shukla A, Kirsch A, Gundeti MS. Multi-Institutional Review of Outcomes and Complications of Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation for Treatment of Primary Vesicoureteral Reflux in Children. J Urol 2017; 197:1555-1561. [DOI: 10.1016/j.juro.2017.01.062] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2017] [Indexed: 12/28/2022]
Affiliation(s)
| | | | - Christina Kim
- Connecticut Children’s Medical Center, Hartford, Connecticut
| | | | - Paul Noh
- Cincinnati Children’s Hospital, Cincinnati, Ohio
| | | | | | - Aseem Shukla
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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李 东, 王 保, 张 旭, 张 为. [Application of robotic-assisted versus conventional laparoscopy in ureteral reimplantation with psoas hitch]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2017; 37:659-662. [PMID: 28539290 PMCID: PMC6780483 DOI: 10.3969/j.issn.1673-4254.2017.05.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To compare the efficacy of robotic-assisted laparoscopic and conventional laparoscopic ureteral reimplantation with psoas hitch. METHODS We retrospectively analyzed the data of 10 patients undergoing robotic-assisted laparoscopic ureteral reimplantation with psoas hitch and 6 undergoing conventional laparoscopic ureteral reimplantation between June, 2013 and December, 2014 in the General Hospital of PLA. The indications, surgical techniques and outcomes of the two procedures were compared. RESULTS All the patients completed the laparoscopic procedures without conversion to open surgery. Robotic-assisted and conventional laparoscopic procedures were comparable in terms of the mean operation time (165.50=52.57 vs 152.50=73.60 min), mean volume of blood loss (81.00=69.35 vs 46.67=31.41 mL), mean duration of catheter retention (6.75=1.74 vs 7.50=2.43 days), and mean postoperative hospital stay (7.10=2.08 vs 8.67=3.14 days). The patients were followed up for a mean of 13.5 months, during which none of the patients experienced anastomotic leak, vesicoureteral reflux or hydronephrosis. CONCLUSION There are no significant differences in surgical indications, surgical techniques or postoperative effect between robotic-assisted and conventional laparoscopic procedures of ureteral reimplantation with psoas hitch, but robotic-assisted laparoscopy can reduced the complexity in operation and increase the surgical precision in patients with a history of pelvic surgery, pelvic adhesion or secondary reimplantation.
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Affiliation(s)
- 东 李
- 广东省人民医院//广东省医学科学院泌尿外科,广东 广州 510080Departmentof Urology, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou 510080, China
| | - 保军 王
- 中国人民解放军总医院泌尿外科,北京 100853Department of Urology, General Hospital of PLA, Beijing 100853, China
| | - 旭 张
- 中国人民解放军总医院泌尿外科,北京 100853Department of Urology, General Hospital of PLA, Beijing 100853, China
| | - 为 张
- 中国人民解放军总医院泌尿外科,北京 100853Department of Urology, General Hospital of PLA, Beijing 100853, China
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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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Baek M, Koh CJ. Lessons learned over a decade of pediatric robotic ureteral reimplantation. Investig Clin Urol 2017; 58:3-11. [PMID: 28097262 PMCID: PMC5240282 DOI: 10.4111/icu.2017.58.1.3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 12/29/2016] [Indexed: 01/04/2023] Open
Abstract
The da Vinci robotic system has improved surgeon dexterity, ergonomics, and visualization to allow for a minimally invasive option for complex reconstructive procedures in children. Over the past decade, robot-assisted laparoscopic ureteral reimplantation (RALUR) has become a viable minimally invasive surgical option for pediatric vesicoureteral reflux (VUR). However, higher-than-expected complication rates and suboptimal reflux resolution rates at some centers have also been reported. The heterogeneity of surgical outcomes may arise from the inherent and underestimated complexity of the RALUR procedure that may justify its reclassification as a complex reconstructive procedure and especially for robotic surgeons early in their learning curve. Currently, no consensus exists on the role of RALUR for the surgical management of VUR. High success rates and low major complication rates are the expected norm for the current gold standard surgical option of open ureteral reimplantation. Similar to how robot-assisted laparoscopic surgery has gradually replaced open surgery as the most utilized option for prostatectomy in prostate cancer patients, RALUR may become a higher utilized surgical option in children with VUR if the adoption of standardized surgical techniques that have been associated with optimal outcomes can be adopted during the second decade of RALUR. A future standard of RALUR for children with VUR whose parents seek a minimally invasive surgical option can arise if widespread achievement of high success rates and low major complication rates can be obtained, similar to the replacement of open surgery with robot-assisted laparoscopic radical prostectomy as the new strandard for men with prostate cancer.
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Affiliation(s)
- Minki Baek
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chester J. Koh
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital and Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
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Herz D, Fuchs M, Todd A, McLeod D, Smith J. Robot-assisted laparoscopic extravesical ureteral reimplant: A critical look at surgical outcomes. J Pediatr Urol 2016; 12:402.e1-402.e9. [PMID: 27522319 DOI: 10.1016/j.jpurol.2016.05.042] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 05/08/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Published reports of outcomes of robot assisted laparoscopic ureteral reimplantation (RALUR) show mixed results that, on average, are inferior to open ureteral reimplant. We present a retrospective analysis of a prospective series of children who had RALUR from 2013 to June 2015. We hypothesized that surgical outcomes are based on identifiable risk variables. We provide a critical analysis of the relationship between patient characteristics and several surgical and non-surgical outcomes. METHODS We reviewed the records of children who had Robot-Assisted Laparoscopic (RAL) Ureteral Reimplant (UR) at Nationwide Children's Hospital. Patient age and gender, preoperative presentation, presence of preoperative bladder and bowel dysfunction (BBD), VUR grade and laterality, indication for operation, operative time, surgical outcome, surgical complications, post-operative prevalence of UTI, and pre- and post-operative status of BBD were recorded. We also recorded techniques for ureteral dissection, and closing the detrusorrhaphy. Surgical outcome was defined by post-operative VCUG. We define BBD based on publications by the standardization committee of International Children's Continence Society (ICCS). All statistical calculations were performed with STATA version 11. RESULTS We performed extravesical RALUR on 54 children for a total of 72 ureters. Overall the study children were 74% female. The mean and median age was 5.2 and 4.9 years, respectively. Mean overall hospital length of stay (LOS) was 1.64 days. The mean LOS was 1.26 for unilateral (RALUUR) and 2.39 days for bilateral (RALBUR) surgeries and was significant (p < 0.05). Overall surgical success was 85.2% of ureters and 84.7% of children. Stratified by unilateral and bilateral surgeries, unilateral success was 91.7%, and bilateral success was 77.8% of ureters, and 72.2% of children. In the 3 failures in the RALUUR group the mean postoperative VUR grade was 1.3 from a pre-op mean grade of 3.3, whereas in the RALBUR group, the mean VUR grade among the failures was 3.0 from a mean pre-op VUR grade of 3.7. Urinary leak from ureteral injury, and urinary obstruction were more common in the RALBUR group. Post-operative urinary retention occurred in 4 children in the RALBUR and none in the RALUUR groups. Four with VUR after RALBUR and one child after RALUUR had open ureteral reimplant. Post-op UTI and non-surgical readmissions were higher in the RALBUR group. CONCLUSIONS Bilateral RALUR is associated with higher failure rates, higher complication rates, higher re-operation rates, and more postoperative UTIs and nonsurgical readmissions compared with unilaterasl RALUR.
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Affiliation(s)
- Daniel Herz
- Nationwide Children's Hospital, Columbus, OH, USA.
| | - Molly Fuchs
- Nationwide Children's Hospital, Columbus, OH, USA
| | - Andrew Todd
- Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Daryl McLeod
- Nationwide Children's Hospital, Columbus, OH, USA
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Abstract
Vesicoureteral reflux (VUR) is the most common underlying etiology responsible for febrile urinary tract infections (UTIs) or pyelonephritis in children. Along with the morbidity of pyelonephritis, long-term sequelae of recurrent renal infections include renal scarring, proteinuria, and hypertension. Treatment is directed toward the prevention of recurrent infection through use of continuous antibiotic prophylaxis during a period of observation for spontaneous resolution or by surgical correction. In children, bowel and bladder dysfunction (BBD) plays a significant role in the occurrence of UTI and the rate of VUR resolution. Effective treatment of BBD leads to higher rates of spontaneous resolution and decreased risk of UTI.
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Affiliation(s)
- Michael L Garcia-Roig
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, USA
| | - Andrew J Kirsch
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, USA
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Arlen AM, Kirsch AJ. Recent Developments in the Use of Robotic Technology in Pediatric Urology. Expert Rev Med Devices 2016; 13:171-8. [DOI: 10.1586/17434440.2016.1136211] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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