Pediatric laparoscopic and robot-assisted laparoscopic surgery: technical considerations

The missed crossing vessel during open pyeloplasty: a potential advantage of the robot-assisted approach in children

OBJECTIVE

To investigate whether the panoramic view offered by robot-assisted laparoscopic pyeloplasty (RALP) reduces the likelihood of missing a crossing vessel compared to open pyeloplasty in cases where initial pyeloplasty fails.

METHODS

A single institution redo-pyeloplasty database was reviewed for children treated between January 2012 to July 2023. Clinical history, imaging and operative details were reviewed to identify the etiology for the redo procedure.

RESULTS

Cohort consisted of 45 patients undergoing a redo RALP during the study period. 29 of 45 patients had an initial open surgical approach, whereas 16 had an initial RALP. 10 patients were noted to have a missed crossing vessel on redo pyeloplasty - 9 had an initial open approach whereas 1 had an initial RALP (p<0.0001).

CONCLUSIONS

RALP may reduce the risk of missing a crossing vessel due to the panoramic view of the surgical field intrinsic to an intraperitoneal RALP approach.

Single-port robotic-assisted laparoscopic synchronous surgery in pediatric patent processus vaginalis

PURPOSE

Patent processus vaginalis (PPV) is usually observed in pediatric abdominal surgery; however, robotic single-port surgery in repairing processus vaginalis has not been reported in children. Herein, we present our clinical experiences in single-port robotic surgeries for PPV repair to evaluate both efficacy and safety.

METHODS

Retrospective analysis of patients underwent single-port robotic-assisted laparoscopic surgery for genitourinary diseases from May 2020 and May 2023 in our center. Among these patients, 21 children had PPV repaired at the same time. The case characteristics and follow-up data were recorded.

RESULTS

Twenty-one of the 53 children were found to have PPV during genitourinary surgery. The simultaneous treatment of the primary disease and PPV with a single-port robotic-assisted platform was both convenient and safe. There was no significant increase in total operation time, and no excessive intraoperative hemorrhage was observed in any of the operations. There were no complications observed on follow-up.

CONCLUSION

With a high incidence of PPV in children, a single-port robotic-assisted procedure is feasible and effective if simultaneously performed when addressing a primary abdominal disease.

Pediatric Robot-Assisted Laparoscopic Pyeloplasty: Where Are We Now?

PURPOSE OF REVIEW

This review aims to provide an in-depth exploration of the recent advancements in robot-assisted laparoscopic pyeloplasty (RALP) and its evolving landscape in the context of infant pyeloplasty, complex genitourinary (GU) anatomy, recurrent ureteropelvic junction (UPJ) obstruction, cost considerations, and the learning curve.

RECENT FINDINGS

Recent literature highlights the safety and efficacy of RALP in treating the infant population, patients with complex GU anomalies, and recurrent UPJO which were all traditionally managed using the open approach. Cost considerations are evolving, with the potential for RALP to have a lesser financial burden. In addition, the learning curve for RALP is diminishing due to robust training programs and advances in research. RALP has become the gold standard in the treatment of UPJO in pediatric urology at many children's hospitals. Surgeon comfort and research in this space allow safe and successful reconstruction in the most challenging of cases.

Advances in Pediatric Surgery Simulation-Based Training

Pediatric surgery is the diagnostic, operative, and postoperative surgical care of children with congenital and acquired anomalies and diseases. The early history of the specialty followed the classic "see one, do one, teach one" philosophy of training but has since evolved to modern methods including simulation-based training (SBT). Current trainees in pediatric surgery face numerous challenges, such as the decreasing incidence of congenital disease and reduced work hours. SBT consists of several modalities that together assist in the acquisition of technical skills and improve performance in the operating room. SBT has evolved to incorporate simulator models and video gaming technology, in parallel with the development of simulation in other surgical and non-surgical pediatric fields. SBT has advanced to a level of sophistication that means that it can improve the skills of not only pediatric surgery trainees but also practicing attending surgeons. In this review, we will discuss the history of pediatric surgery, simulation in pediatric surgery training, and the potential direction of pediatric surgical simulation training in the future.

Robotic-assisted pyeloplasty in children: a systematic review of the literature

Robotic pyeloplasty has become a natural progression from the development of open, then laparoscopic procedures to treat pediatric patients with ureteropelvic junction obstruction (UPJO). Robotic-assisted pyeloplasty (RALP) is now considered a new gold standard in pediatric MIS. A systematic review of the literature retrieved from PubMed and published in the last 10 years (2012-2022) was performed. This review underlines that in all children except the smallest infants, where the open procedure has benefits in terms of duration of general anesthetic and there are limitations in the size of instruments, robotic pyeloplasty is becoming the preferred procedure to perform in patients with UPJO. Results for the robotic approach are extremely promising, with shorter operative times than laparoscopy and equal success rates, length of stay and complications. In case of redo pyeloplasty, RALP is easier to perform than other open or MIS procedures. By 2009, robotic surgery became the most used modality to treat all UPJO and continues to grow in popularity. Robot-assisted laparoscopic pyeloplasty in children is safe and effective with excellent outcomes, even in redo pyeloplasty or challenging anatomical cases. Moreover, robotic approach shortens the learning curve for junior surgeons, who can readily achieve levels of expertise comparable to senior practitioners. However, there are still concerns regarding the cost associated with this procedure. Further high-quality prospective observational studies and clinical trials, as well as new technologies specific for the pediatric population, are advisable for RALP to reach the level of gold standard.

Laparoscopic vs open portoenterostomy in biliary atresia: a systematic review and meta-analysis

Hepatoportoenterostomy remains the cornerstone of treatment for biliary atresia. Current employed techniques include laparoscopy and open surgery. This study aims to determine if either method provides an advantage. Following PRISMA guidelines, a systematic review was conducted. Nineteen studies were included. Mean operative time 34.98 (95% CI 20.10, 49.85; p ≤ 0.00001) was longer in laparoscopic while bleeding volumes - 16.63 (95% CI - 23.39, - 9.86; p ≤ 0.00001) as well as the time to normal diet - 2.42 (95% CI - 4.51, - 0.32; p = 0.02) were lower in the laparoscopic group. No differences were observed in mean length of stay - 0.83. Similar complication, transfusions, postoperative cholangitis 0.97, and transplant free survival rates 1.00 (0.63, 1.60; p = 0.99) were seen between groups. Laparoscopic portoenterostomy provides advantages on operative time and bleeding as well as to normal diet when compared to open procedures. Both procedures showed no differences in length of stay, complications, cholangitis, and importantly, native liver survival. Level of evidence: III.

Surgical outcomes are equivalent after pure laparoscopic and robotic-assisted pyeloplasty for ureteropelvic junction obstruction

INTRODUCTION

Minimally invasive (robotic and pure laparoscopic) pyeloplasty has been increasingly used for treatment of ureteropelvic junction obstruction (UPJO). However, few large-scale studies have compared these two modalities directly.

METHODS

We performed a retrospective single-center review of all patients who underwent pure laparoscopic (LP) or robotic pyeloplasty (RALP) between 2007 and 2018. Patients were excluded if the initial surgery at our institution was a redo pyeloplasty or if they lacked follow-up information. Outcomes of interest included operative time, length of stay, and complication rates, including rates of secondary procedures. We compared these outcomes between groups using Student's t test for continuous variables and a Chi-square for categorical variables.

RESULTS

A total of 282 patients were identified. Forty-eight were excluded based on study criteria; therefore, our total study cohort was 234 patients: 119 RALP and 115 LP cases. Overall mean postoperative follow-up time was 20.8 months, with no significant differences between groups. Mean operative time was shorter in the LP group when compared the RALP group (3 h 7 min vs. 3 h 41 min, p < 0.001). There were no significant differences between groups in length of stay (1.22 days vs 1.50 days, p = 0.095). Complications occurred in 52 patients (22.2% of overall cohort) with no difference in incidence between groups. Twenty-five patients (14 in the RALP group and 11 in the LP group) underwent unplanned secondary procedures; 19 of these patients (9 in the RALP group and 10 in the LP group) needed a procedure to address secondary obstruction.

CONCLUSION

We demonstrated no significant differences between RALP and LP in regards to complication rates. Surgeons performing RALP and LP have the potential to offer the same level of care for the surgical management of UPJO, especially in countries where robotic technology may not be readily available.

Robot-assisted vs laparoscopic pyeloplasty in children with uretero-pelvic junction obstruction (UPJO): technical considerations and results

BACKGROUND

Although both laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP) have reported excellent clinical outcomes, no evidence is currently available about the best surgical approach for surgical treatment of children with uretero-pelvic junction obstruction (UPJO).

OBJECTIVE

This study aimed to compare the outcomes of LP and RALP in children with UPJO.

STUDY DESIGN

The medical records of all patients with UPJO, who underwent LP or RALP in three pediatric urology units over a 2-year period, were retrospectively reviewed. The authors excluded open pyeloplasty and cases with complex anatomy such as horseshoe kidney. A dismembered Anderson-Hynes pyeloplasty was performed in all cases.

RESULTS

Sixty-seven patients (39 boys and 28 girls) with a median age of 4 years (range 8 months-14 years) were included. Thirty-seven patients (55.2%) underwent RALP, and 30 patients (44.8%) underwent LP. Three patients of RALP group presented a recurrent UPJO. No significant difference was found in the median total operative time between RALP (133 min) and LP (139 min) (P = 0.33). The median anastomotic time was significantly shorter in RALP (79 min) compared with LP (105.5 min) (P = 0.001). Overall surgical success rate was 96.7% for LP and 100% for RALP (P = 0.78). As for postoperative complications, the authors recorded re-stenosis of UPJO in one LP patient (3.3%), who underwent redo-RALP.

DISCUSSION

According to the authors experience, robotic surgery should be indicated in patients older than 18-24 months with a body weight > 10-15 Kgs. Laparoscopic pyeloplasty requires advanced laparoscopic skills related to intracorporeal suturing. However, the learning curve of suturing in robotics is much shorter compared with laparoscopy. In fact, during LP, the authors have to place 2-3 transabdominal stay sutures to stabilize the uretero-pelvic junction, before performing the anastomosis. Conversely, the authors never needed to place stay sutures in RALP.

CONCLUSIONS

The study experience suggested that RALP and LP give excellent results in children with UPJO. Laparoscopic pyeloplasty can be considered more minimally invasive than RALP because 3-mm trocars are adopted instead of 8-mm robotic ports. However, LP is technically challenging and has a bad ergonomics for the surgeon. Conversely, RALP is technically easier compared with LP, especially in redo procedures, with an excellent ergonomics. The main disadvantages of RALP remain high costs and size of robotic instruments. The choice to perform LP or RALP should be tailored to the individual case, considering patient's age and surgeon's experience.

Bladder Reconstruction with Bowel: Robot-Assisted Laparoscopic Ileocystoplasty with Mitrofanoff Appendicovesicostomy in Pediatric Patients

Neurogenic bladder occur as a consequence of several conditions, most commonly posterior urethral valves syndrome, spina bifida, tethered cord, sacral agenesis, and Arnold-Chiari malformation. It is characterized by diminished bladder capacity and/or reduced compliance, associated with high-pressure voiding that can lead to deterioration of renal function if left untreated. When medical management fails, bladder reconstruction with bowel (aumentation ileocystoplasty) becomes the treatment of choice for these patients. In most cases, it is accompanied by the creation of a continent catheterizable channel, with the appendix being the most commonly used conduit (Mitrofanoff appendicovesicostomy). Conventional open surgery has proven to be an efficient and safe approach in these patients. However, robot-assisted surgery not only offers a cosmetic advantage, but also results in a shorter hospital stay, less postoperative pain, and even decreased number of adhesions (as shown in porcine models). Nevertheless, the complexity of this technique has limited the wide adoption of this approach. We seek to provide a technical guide to robot-assisted laparoscopic ileocystoplasty and Mitrofanoff appendicovesicostomy in pediatric patients, as well as a critical review of literature about the perioperative care of these patients.

Removal of pediatric stage IV neuroblastoma by robot-assisted laparoscopy: A case report and literature review

BACKGROUND

Neuroblastoma (NB) is the most common extracranial solid tumor in children, with an incidence of approximately 1/10000. Surgical resection is an effective treatment for children with NB. Robot-assisted laparoscopic surgery is a new method and is superior to conventional laparoscopic surgery, since it has been preliminarily applied in clinical practice with a significant curative effect. This paper discusses significance and feasibility of complete resection of stage IV NB using robot-assisted laparoscopic surgery, while comparing its safety and effectiveness with conventional laparoscopic surgery.

CASE SUMMARY

In June 2018, a girl with stage IV retroperitoneal NB, aged 3 years and 5 mo, was admitted. Her weight was 15 kg, and her height was 100 cm. Robot-assisted, five-port laparoscopic resection of NB was performed. Starting from the middle point between the navel and the anterior superior iliac spine to the left lower abdomen, the pneumoperitoneum and observation hole (10 mm) were established using the Hasson technique. Operation arm #1 was located between the left anterior axillary line, the navel, and the costal margin (8 mm); operation arm #2 was located at the intersection of the right anterior axillary line and Pfannenstiel line (8 mm); one auxiliary hole was located between arm #2 (on the Pfannenstiel line) and the observation hole (12 mm); and another auxiliary hole (5 mm) was located slightly below the left side of the xiphoid. Along the right line of Toldt and the hepatic flexure of the transverse colon, the colon was turned to the left and below with a hook electrode. Through Kocher's incision, the duodenum and the pancreatic head were turned to the left to expose the inferior vena cava and the abdominal aorta. The vein was separated along the right external iliac, and the inferior vena cava was then lifted to expose the right renal vein from the bottom to the top. The tumor was transected horizontally below the renal vein, and it was first cut into pieces and then resected. The right renal artery and the left renal vein were also exposed, and the retrohepatic inferior vena cava was isolated. The tumor was resected along the surface of the psoas muscle, the back of the inferior vena cava, and the right side of the abdominal aorta. Finally, the lymph node metas-tases in front of the abdominal aorta and left renal vein were completely removed. The specimens were loaded into a disposable specimen retrieval bag and removed from the enlarged auxiliary hole. T-tube drainage was placed and brought out through a hole in the right lower quadrant of the abdomen. The operative time was 389 min, the time of pneumoperitoneum was 360 min, the intraoperative blood loss was approximately 200 mL, and the postoperative recovery was smooth. There were no complications, such as lymphatic fistula, diarrhea, bleeding, and paralytic ileus. Two months after discharge, there were no other complications. The literature on the application of robot-assisted laparoscopic surgery in the treatment of NB in children was reviewed

CONCLUSION

The robot has the advantages of a three-dimensional view and flexible operation, and it can operate finely along blood vessels. The successful experience of this case confirmed that robot-assisted laparoscopic surgery can skeletonize the abdominal blood vessels in the tumor and cut the tumor into pieces, indicating that robot-assisted laparoscopic surgery is feasible.

Robotic Urologic Surgery in the Infant: a Review

PURPOSE OF REVIEW

The goal of this article is to review the current role of robotic urologic surgery in the infant population across a spectrum of diseases and procedures.

RECENT FINDINGS

Robotic urological surgery has been performed in the infant population across a variety of conditions including ureteropelvic junction obstruction, vesicoureteral reflux, and duplicated and nonfunctional renal moieties. However, most of the durable evidence showing safety and success remains in the repair of the obstructed ureteropelvic junction. Included in this review are also strategies to address the limitations imposed by the unique physiology and anatomy of the infant. Robotic urologic surgery remains an alternative to other surgical approaches in the properly selected infant in the hands of experienced surgeons. As additional larger studies are performed, the utility of the robotic platform in this population will be clearer.

Laparoendoscopic Single-Site (LESS) Surgery in Pediatric Urology: A 4-Year Experience

Objective

The aim of the study was to assess the feasibility and outcomes of pediatric urological laparoendoscopic single-site (LESS) surgery.

Materials and Methods

We retrospectively collected charts of all patients who underwent LESS procedures in our department from January 2013 to December 2016. Data included demographic characteristics, type of procedures, intraoperative details, hospital stay, and complications. The umbilicus was used as the surgical site in all cases. All procedures were performed with a homemade glove port and standard straight 3- or 5-mm laparoscopic instruments.

Results

Seventy-three patients (55 males, 18 females) were identifed. Procedures included 46 orchidop-exies, 21 pyeloplasties, 8 varicocelectomies, 3 nephrecto-mies, 3 nephroureterectomies, 3 orchiectomies, and 1 renal hydatid cyst treatment. Median operative time for the entire cohort was 47 min (range 26-156 min). There was no signifcant intraoperative blood loss. No conversion to conventional laparoscopy or open surgery was needed. All patients required paracetamol postoperatively. The mean follow-up was 18 months. Two patients had testicular atrophy after a Fowler-Stephens procedure and 1 patient had testicular reascension. Cosmetic results were excellent. Forty-five (62.5%) patients were discharged on the day of surgery.

Conclusion

Our study demonstrated that LESS surgery using our glove port technique and conventional laparoscopic instruments is a feasible and safe technique for the surgical management of various pediatric urological conditions.

From Laparoscopic Pyeloplasty to Robot-Assisted Laparoscopic Pyeloplasty in Primary and Reoperative Repairs for Ureteropelvic Junction Obstruction in Children

PURPOSE

Robot-assisted laparoscopic pyeloplasty (RALP) and laparoscopic pyeloplasty (LP) are both minimally invasive surgical options to correct ureteropelvic junction obstruction in children. There are limited data reporting surgeons' experience of switching from LP to RALP and comparing the outcomes of the two procedures.

METHODS

We conducted a retrospective study on 63 consecutive children who underwent either LP or RALP by the same surgeon in a tertiary center from January 2008 to November 2016. LP had been the standard practice until January 2014 when it was replaced by RALP in short transition.

RESULTS

Thirty-seven LP and 26 RALP were successfully performed in children aged 2 months to 16 years. There was no difference between the two groups in age, body weight, laterality, clinical presentations, preoperative imagings, primary/reoperative repairs. The overall success rates were 34/37 (91.9%) and 25/26 (96.2%) for LP and RALP, respectively (P > .05). RALP was associated with shorter length of stay (3.1 days versus 4.0 days; P = .03). Surgeon-in-training participation was greater in RALP group (P < .001). There was no difference in operative time, complication rates, and analgesic requirement between the two groups.

CONCLUSIONS

Surgeons proficient in LP can adapt quickly to RALP, achieving comparable outcomes. Robotic technology may facilitate training on minimally invasive pyeloplasty.

First experience of robotic spleen-preserving distal pancreatectomy in a child with insulinoma

Background

An insulinoma is a functional neuroendocrine pancreatic tumor, and surgical resection is indicated. Robot-assisted laparoscopic surgeries have been shown to be generally safe and feasible for treatment of pediatric cases of urologic and digestive disease.

Case presentation

In July 2016, a 9-year-old girl (24 kg, 120 cm) was admitted with a pancreatic tail insulinoma and underwent robot-assisted spleen-preserving laparoscopic distal pancreatectomy. The total procedure time was 155 min, and the blood loss was about 10 ml. The patient recovered without complications.

Conclusions

This case supports that robot-assisted spleen-preserving laparoscopic distal pancreatectomy may be safe and feasible in pediatric insulinoma patients.

Laparoendoscopic single-site surgery (LESS) for major urological procedures in the pediatric population: A systematic review

BACKGROUND

Improvements in laparoscopic surgery have led to the introduction of laparoendoscopic single-site surgery (LESS) as an alternative to conventional laparoscopy conferring a number of possible advantages. In this review, we aim to elucidate the aspects of LESS for major urological procedures in the pediatric population.

MATERIALS AND METHODS

An in-depth search of the literature was performed in the databases of PubMed and Scopus, for studies investigating the technical aspects and clinical outcomes of partial nephrectomies, nephrectomies, nephroureterectomies, varicocelectomies and pyeloplasties in children. Data on parameters such as operation time, instrumentation, perioperative complications, hospital stay and follow up period were collected and further analyzed cumulatively.

RESULTS

Twenty nine studies met the inclusion criteria incorporating 386 patients who underwent 401 procedures. There were no major intraoperative complications, with only 19 patients (4.73%) facing postoperative complications. No perioperative deaths were reported.

CONCLUSIONS

In the hands of experienced surgeons LESS seems a feasible, efficient and less invasive alternative to standard laparoscopy in the field of pediatric urology. There is an eminent need of well-designed randomized controlled trials comparing the two techniques.

Umbilical only access laparoscopic pyeloplasty in children: Preliminary report

BACKGROUND

Over the past three decades, laparoscopic surgery has become a well-established alternative to open surgery in the management of ureteropelvic junction (UPJ) obstruction. Currently, several efforts are being made, aimed at further reducing the morbidity associated with conventional laparoscopy. We report our experience with modified umbilical port laparoscopic pyeloplasty in children.

MATERIALS AND METHODS

Children presenting with hydronephrosis secondary to UPJ obstruction formed the study group. A 5 mm endoscopic port was placed on the inferior umbilical crease. The two 3 mm instruments were introduced through puncture sites created a few mm superior and lateral to the endoscopic port, under vision. Total operating time, the time taken for insertion of double pigtail catheter, time taken for pyeloplasty anastomosis and complications were noted.

RESULTS

During the study period, 16 children underwent modified umbilical only access laparoscopic pyeloplasty. The total operating time and the time for insertion of double pigtail catheter were significantly more in our earlier half of cases.

CONCLUSIONS

Modified umbilical port laparoscopic pyeloplasty reduces the morbidity associated with conventional multiport laparoscopy without the need of expensive multichannel cannulas, curved laparoscopic instruments and longer laparoscopic endoscopes. Though crossing instruments are a factor which prolongs the duration of surgery, it does not hinder complex suturing needed during pyeloplasty.

Comparing the efficacy and safety between robotic-assisted versus open pyeloplasty in children: a systemic review and meta-analysis

OBJECTIVE

This manuscript is mainly to systemically review the published reports that compared the efficacy and safety of robotic-assisted (RP) versus open pyeloplasty (OP) in children with ureteropelvic junction obstruction (UPJO).

METHODS

We did a systemic search in the PubMed(®) for all randomized controlled trials or comparative studies that compared the surgical results of robotic versus open pyeloplasty in children with UPJO. Two of the authors (Hsu and Chang) independently did the literature search, quality assessment, and data extraction. The obtained data were analyzed with Cochrane Collaboration Review Manager (RevMan(®), version 5.3). The end points of the analysis and review included age, operative time, hospital stay, costs, complications, and success rate.

RESULTS

In total, seven comparative trials and three studies using national database met the criteria that comprised 20,691 (RP:OP = 1956:18,735) patients in the meta-analysis. Most studies reported median value of patient age, operative time, and hospital stay. Only a small proportion of studies could be included for meta-analysis. The enrolled trials revealed that RP was more frequently performed in older children, required longer operative time, and shorter hospital stay. The postoperative success rate was comparable (RR = 0.99, 95 CI 0.94-1.04). Comparing with OP, there was a significant higher complication rate (RR = 1.29, 95 CI 1.10-1.51) and higher costs in the RP group.

CONCLUSION

Robotic-assisted pyeloplasty may be a promising alternative minimal invasive surgery for UPJO in children if the higher complication rates and higher costs in the RP can be overcome in the near future.

Training potential in minimally invasive surgery in a tertiary care, paediatric urology centre

BACKGROUND

Minimally invasive surgery (MIS) is being utilized more frequently as a surgical technique in general surgery and in paediatric urology. It is associated with a steep learning curve. Currently, the centre does not offer a MIS training programme. It is hypothesized that the number of MIS procedures performed in the low-volume specialty of paediatric urology will offer insufficient training potential for surgeons.

OBJECTIVE

To assess the MIS training potential of a highly specialized, tertiary care, paediatric urology training centre that has been accredited by the Joint Committee of Paediatric Urology (JCPU).

STUDY DESIGN

The clinical activity of the department was retrospectively reviewed by extracting the annual number of admissions, outpatient consultations and operative procedures. The operations were divided into open procedures and MIS. Major ablative procedures (nephrectomy) and reconstructive procedures (pyeloplasty) were analysed with reference to the patients' ages. The centre policy is not to perform major MIS in children who are under 2 years old or who weigh less than 12 kg.

RESULTS

Every year, this institution provides approximately 4300 out-patient consultations, 600 admissions, and 1300 procedures under general anaesthesia for children with urological problems. In 2012, 35 patients underwent major intricate MIS: 16 pyeloplasties, eight nephrectomies and 11 operations for incontinence (seven Burch, and four bladder neck procedures). In children ≥2 years of age, 16/21 of the pyeloplasties and 8/12 of the nephrectomies were performed laparoscopically. The remaining MIS procedures included 25 orchidopexies and one intravesical ureteral reimplantation.

DISCUSSION

There is no consensus on how to assess laparoscopic training. It would be valuable to reach a consensus on a standardized laparoscopic training programme in paediatric urology. Often training potential is based on operation numbers only. In paediatric urology no minimum requirement has been specified. The number of procedures quoted for proficiency in MIS remains controversial. The MIS numbers for this centre correspond to, or exceed, numbers mentioned in other literature. To provide high-quality MIS training, exposure to laparoscopic procedures should be expanded. This may be achieved by centralizing patients into a common centre, collaborating with other specialities, modular training and training outside the operating theatre.

CONCLUSION

Even in a high-volume, paediatric urology educational centre, the number of major MIS procedures performed remains relatively low, leading to limited training potential.

How to decide which infant can have robotic surgery? Just do the math

BACKGROUND

In pediatric urology, robot-assisted surgery has overcome several impediments of conventional laparoscopy. However, workspace has a major impact on surgical performance. The limited space in an infant can significantly impede the mobility of robotic instruments. There is currently no consensus on which infant can undergo robotic intervention and no parameters to help make this decision, especially for those surgeons at the start of their learning curve.

OBJECTIVE

We sought to evaluate our experience with infants to create an objective standard to determine which patients may be most suitable for robotic surgery.

STUDY DESIGN

We prospectively evaluated 45 infants (24 males, 21 females), aged 3-12 months old, who underwent a robotic intervention for either upper or lower urinary tract pathology. At the preoperative office visit the attending surgeon measured the distance between both anterior superior iliac spines (ASIS) as well as the puboxyphoid distance (PXD), regardless of whether the approach was for upper or lower tract disease. Patients' weights were also noted. During surgery, we recorded the number of robotic collisions as well as console time. All surgeries were performed utilizing the da Vinci Si Surgical System by a single surgeon.

RESULTS

There were no differences in ASIS, PXD, collisions or console time when stratified by gender, age or weight. When arranging by upper or lower tract approach, there was no difference in the number of collisions. There was a strong inverse relationship between both ASIS distance and PXD and the number of collisions. Additionally, there was a strong correlation between the number of collisions and console time (Fig. 1). Using a cutoff of 13 cm for the ASIS, there were significantly fewer collisions in the >13 cm group as compared to the ≤13 cm group. This was also true for the PXD using a cutoff of 15 cm: there were significantly fewer collisions in the >15 cm group as compared to the ≤15 cm group.

DISCUSSION

Safe proliferation of robotic technology in the infant population is, in part, dependent on careful patient selection. Our data demonstrated a reduction in instrument collisions and console time with increasing anterior superior iliac spine and puboxyphoid distances. Neither age nor weight was correlated with these measurements, the number of instrument collisions or console time. Limitations include that this is a single institution study with all infants being operated on by a single surgeon. Therefore, the findings of this study may not be generalizable to a less experienced surgeon. Yet, we believe that ASIS and PXD measurements can be used as a guide for the novice surgeon who is beginning to perform robotic-assisted surgery in infants.

CONCLUSION

We found that surgeon ability to perform robotic surgery in an infant is restricted by collisions when the infant has an ASIS measurement of 13 cm or less or a PXD of 15 cm or less. Objective assessment of anterior superior iliac spine and puboxyphoid distance can aid in selecting which infants can safely and efficiently undergo robotic intervention with a minimum of instrument collision, thereby minimizing operative time.

Robotic-Assisted Procedures in Pediatric Surgery: A Critical Appraisal of the Current Best Evidence in Comparison to Conventional Minimally Invasive Surgery

INTRODUCTION

In recent years, the use of robotic-assisted surgery (RAS) has expanded within pediatric surgery. Although increasing numbers of pediatric RAS case-series have been published, the level of evidence remains unclear, with authors mainly focusing on the comparison with open surgery rather than the corresponding laparoscopic approach. The aim of this study was to critically appraise the published literature comparing pediatric RAS with conventional minimally invasive surgery (MIS) in order to evaluate the current best level of evidence.

MATERIALS AND METHODS

A systematic literature-based search for studies comparing pediatric RAS with corresponding MIS procedures was performed using multiple electronic databases and sources. The level of evidence was determined using the Oxford Centre for Evidence-based Medicine (OCEBM) criteria.

RESULTS

A total of 20 studies met defined inclusion criteria, reporting on five different procedures: fundoplication (n=8), pyeloplasty (n=8), nephrectomy (n=2), gastric banding (n=1), and sleeve gastrectomy (n=1). Included publications comprised 5 systematic reviews and 15 cohort/case-control studies (OCEBM Level 3 and 4, respectively). No studies of OCEBM Level 1 or 2 were identified. Limited evidence indicated reduced operative time (pyeloplasty) and shorter hospital stay (fundoplication) for pediatric RAS, whereas disadvantages were longer operative time (fundoplication, nephrectomy, gastric banding, and sleeve gastrectomy) and higher total costs (fundoplication and sleeve gastrectomy). There were no differences reported for complications, success rates, or short-term outcomes between pediatric RAS and conventional MIS in these procedures. Inconsistency was found in study design and follow-up with large clinical heterogeneity.

CONCLUSIONS

The best available evidence for pediatric RAS is currently OCEBM Level 3, relating only to fundoplication and pyeloplasty. Therefore, higher-quality studies and comparative data for other RAS procedures in pediatric surgery are required.

Impact of laparoscopy for diagnosis and treatment in patients with disorders of sex development

OBJECTIVE

To review laparoscopy in patients with disorders of sex development (DSD) in order to clarify its usefulness in diagnosis, devising subsequent therapeutic strategies and managing patients with various conditions.

PATIENTS AND METHODS

Between April 1992 and December 2012, 29 laparoscopic surgeries were performed in 25 DSD patients. Among them, ten were diagnostic laparoscopy including gonadal biopsy, and 19 were therapeutic laparoscopy. Surgical procedures and complications were evaluated.

RESULTS

For diagnostic laparoscopy, laparoscopic gonadal biopsy was performed in three patients. Inspection, with or without open gonadal biopsy, was performed on four out of seven patients with 46XY DSD or mixed gonadal dysgenesis (MGD). Additional surgery was planned and performed based on diagnostic laparoscopic findings in six out of seven patients. In the three patients with ovotesticular DSD, the gonadal pathology was diagnosed as: testis/ovary in one, testis/ovotestis in one and ovary/ovotestis in one--this was from the laparoscopic inspection and/or gonadal biopsy. However, the final diagnoses were bilateral ovotestis in two patients and ovary/ovotestis in one patient. For therapeutic laparoscopy, surgical procedures were: gonadectomy in 17 patients (bilateral in 13, unilateral in three, partial in two); hysterectomy in two patients; orchiopexy in one; and sigmoid vaginoplasty in one patient (included multiple procedures). There were no severe perioperative complications. In the four patients with a history of diagnostic laparoscopy, no severe intra-abdominal adhesions that would disturb therapeutic laparoscopic surgery were observed.

CONCLUSION

While diagnostic laparoscopy was helpful in devising a therapeutic surgical strategy in most of the patients with DSD who were suspected as having complex gonadal status or Müllerian duct derivatives, attention must be paid to precisely diagnosing the gonadal status in ovotesticular DSD. On the other hand, therapeutic laparoscopic surgeries were valuable procedures in treating DSD patients, even with a history of previous diagnostic laparoscopy.

[Laparoscopic robot-assisted partial nephrectomy with total ureterectomy in a symptomatic complete duplicated system: advantages of transperitoneal approach]

We report the case of a laparoscopic robot assisted left upper polar partial nephrectomy with total ureterectomy performed in a teenager. A 14 year-old girl was referred to our institution for stress urinary incontinence. The morphological assessment (ultrasound scan and uro-MRI) showed a double collecting system with a complete ureteral duplication complicated by a dysplasia of the upper moiety of the duplex left kidney and a mega ureter. The surgery started on a lateral decubitus position by the upper polar partial nephrectomy and the ureter section behind superior polar renal vessels. The patient was placed in a supine position and the mega ureter was released and sectioned at the level of the distal adynamic segment in the left uterine parameter. The transperitoneal route was chosen as it provides a large workspace and allows the dissection of the ureters into their pelvic portion by a simple repositioning of the robot ports without additional incision and without any modification of the operative field. No intraoperative and postoperative complication was noticed. Laparoscopic robotic assisted surgery in pediatric urology is increasing, and to our knowledge, we reported this technique and surgery for the first time in France and in children. In the reported case, we showed that the robotic minimally invasive surgery in children is an innovative and safe technique for the treatment of symptomatic upper urinary tract malformations.

Patient positioning and port placement for robot-assisted surgery

Abstract The introduction of robotic surgical systems and their integration into minimally invasive procedures have changed the landscape of laparoscopic surgery dramatically. Intuitive Surgical's da Vinci Surgical System was first approved by the Food and Drug Administration for cardiothoracic procedures in the late 1990s. This trend quickly spread through other surgical specialties, with urologists as one of the frontrunners in adoption. Subsequently, pediatric urologists have adopted robot-assisted procedures in selected centers, performing procedures such as pyeloplasty for ureteropelvic junction obstruction, partial and complete nephrectomy, and both intravesical and extravesical ureteral reimplantation. In this article, we will discuss technical considerations related to patient positioning and port placement in pediatric robot-assisted surgery.

Magnetic resonance urography and laparoscopy in paediatric urology: a case series

Paediatric urology often presents challenging scenarios. Magnetic resonance urography (MRU) and laparoscopy are increasingly used. We retrospectively studied children affected by a disease of the upper urinary tract who after MRU were elected for laparoscopic treatment. This pictorial essay draws on our experience; it illustrates some specific MRU findings and highlights the usefulness of MRU for the diagnosis of upper urinary tract pathology in children. It also offers some examples of the potential additional diagnostic information provided by laparoscopy as well as its therapeutic role.

Trends in robot-assisted laparoscopic pyeloplasty in pediatric patients

OBJECTIVE

To evaluate the incidence of pediatric robotic-assisted laparoscopic pyeloplasties (RALPs) and to determine if there were regional or age-related trends associated with the performance of RALP.

METHODS

Using 2005-2010 data from the Nationwide Inpatient Sample (NIS), the incidence of and trends in pyeloplasty in patients less than 18 years of age were assessed. This was broken down by open, laparoscopic, and robotic techniques when possible. Multiple logistic regression determined which characteristics were associated with increased performance of RALP. Population weighting was used to estimate national rates.

RESULTS

A total of 15,498 pediatric pyeloplasties were performed between 2005 and 2010. Coding for robotics began at the end of 2008, and, since then, 750 of the 5557 pediatric pyeloplasties were robotic. The rate of RALP remained unchanged from 2008-2010 (odds ratio [OR] 0.93, P = .051); however, there was an overall increase in minimally invasively procedures (RALP or laparoscopic) since 2005 (OR 1.4, P <.001). Factors associated with increased performance of RALP were aged above 11 years (OR 50.3, P <.001) and living in the northeast (OR 3.0, P = .001), midwest (OR 2.9, P = .001), or west (OR 4.31, P <.001) compared with the south.

CONCLUSION

An estimated 750 robotic pyeloplasties were performed in the United States between the end of 2008 and 2010. There was an increase in the total number of pyeloplasties performed using minimally invasive techniques since 2005. Older children are more likely and patients living in the south are less likely to be treated with robotic assistance.

Advances in the surgical pediatric urologic armamentarium

The surgical armamentarium of the pediatric urologist has changed greatly in the past 2 decades on account of new technology and careful adaptation of minimally invasive techniques in children. Conventional laparoscopy, robotic-assisted laparoscopy, laparoendoscopic single-site surgery, and endourologic surgery have, to varying degrees, provided new approaches to urologic surgery in the pediatric population. This article reviews the technology and adaptations behind these recent advances as well as their current applications in management of urologic disease in children.