Robot-Assisted Surgery: Current Status Evaluation in Abdominal and Urological Pediatric Surgery

Cost-effectiveness analysis of robot-assisted laparoscopic surgery for complex pediatric surgical conditions

BACKGROUND

Robotics has been used safely and successfully in a variety of adult surgeries and is gradually gaining ground in pediatrics. While the benefits of robotic-assisted surgery in disease treatment are well recognized, its high cost has led to questions. To investigate whether robotic-assisted laparoscopic surgery (RALS) is cost-effective compared to conventional laparoscopic surgery (LS) in pediatric surgery, we attempted to construct a model to perform an analysis of these two surgical approaches using Python statistical analysis software.

METHODS

We selected four common complex pediatric surgical conditions (choledochal cyst, Hirschsprung's disease, vesicoureteral reflux, and congenital hydronephrosis) from three systems (pediatric hepatobiliary, gastroenterology, and urology). Models were constructed using Python statistical software to compare hospital costs and surgical outcomes for RALS and LS. In addition, we performed a preferred strategy analysis for both surgical modalities while assessing model uncertainty using one-way sensitivity analysis.

RESULTS

For the four diseases, the operative time decreased sequentially. The total inpatient costs of RALS were 10,816.72, 9145.44, 8414.29, 7973.58 dollars, respectively, yielding 1.789, 1.712, 1.749, 1.792 quality adjustment life years (QALYs) over two years post-operatively. The incremental cost of RALS relative to LS for each disease was 3523.44, 3200.20, 3049.79, 3043.66 dollars, respectively, with an incremental utility of 0.060, 0.054, 0.051, 0.050 QALYs. The incremental cost-effectiveness ratios (ICERs) for RALS for each of the four diseases were 58,724.01, 59,262.95, 59,799.79, 60,873.20 dollars/QALY, all less than 100,000 dollars/QALY. The cost of robot consumables was the main incremental cost of RALS and had the most significant impact on the model.

CONCLUSION

For the four pediatric surgical conditions described above, RALS has higher inpatient costs than LS, but it has better postoperative outcomes, and all four RALS treatments are cost-effective. Children with complex diseases and long operative times appear to benefit more from RALS.

Robotic-assisted colectomy in children: a comparative study with laparoscopic surgery

The aim of this study was to compare outcomes of laparoscopic and robotic-assisted colectomy in children. All children who underwent a colectomy with a laparoscopic (LapC) or robotic-assisted (RobC) approach in our institution (January 2010-March 2023) were included. Demographics, surgical data, and post-operative outcomes within 30 days were collected. Additional cost related to the robotic approach was calculated. Comparisons were performed using Fisher tests for categorical variables and Mann-Whitney tests for continuous variables. A total of 55 colectomies were performed: 31 LapC and 24 RobC (median age: 14.9 years). Main indications included: inflammatory bowel disease (n = 36, 65%), familial adenomatous polyposis (n = 6, 11%), sigmoid volvulus (n = 5, 9%), chronic intestinal pseudo-obstruction (n = 3, 5%). LapC included 22 right, 4 left, and 5 total colectomies. RobC included 15 right, 4 left, and 5 total colectomies. Robotic-assisted surgery was associated with increased operative time (3 h vs 2.5 h, p = 0.02), with a median increase in operative time of 36 min. There were no conversions. Post-operative complications occurred in 35% of LapC and 38% of RobC (p = 0.99). Complications requiring treatment under general anesthesia (Clavien-Dindo 3) occurred in similar rates (23% in LapC vs 13% in RobC, p = 0.49). Length of hospitalization was 10 days in LapC and 8.5 days in RobC (p = 0.39). The robotic approach was associated with a median additional cost of 2156€ per surgery. Robotic-assisted colectomy is as safe and feasible as laparoscopic colectomy in children, with similar complication rates but increased operative times and cost.

Day Surgery in Children Undergoing Retroperitoneal Robot-assisted Laparoscopic Pyeloplasty: Is It Safe and Feasible?

Background

Robot-assisted pyeloplasty is the most frequently performed robotic procedure in children. A retroperitoneal approach limits surgical trauma and avoids peritoneal irritation. This led to the establishment of the criteria for day surgery (DS) and a related clinical care pathway.

Objective

To assess the feasibility and safety of DS in children undergoing retroperitoneal robot-assisted laparoscopic pyeloplasty (R-RALP).

Design setting and participants

We performed a bicentric prospective study (NCT03274050) over 2 yr involving the two major paediatric urology teaching hospitals in Paris. A clinical pathway and a prospective research protocol were specifically established.

Intervention

DS in selected children undergoing R-RALP.

Outcome measurements and statistical analysis

The primary outcomes were DS failure, 30-d complications, and readmission rates. The secondary outcomes included preoperative characteristics, perioperative parameters, and surgical outcomes. Quantitative variables were expressed as medians with interquartile ranges.

Results and limitations

Thirty-two children fulfilled specific inclusion criteria and were consecutively selected for DS following R-RALP. The median patient age was 7.6 yr (4.1-11.8) and weight 25 kg (14-45). The median console time was 137 min (108-167). There were no intraoperative complications or conversions. Six children were kept under observation overnight and discharged the following day due to persistent pain (n = 3), parental anxiety (n = 2), or a prolonged procedure (n = 1). The median duration of hospital stay of the 26 children in the DS setting was 12.7 h (12.2-13.2). During the 30-d period, there were four emergency room visits (15%) resulting in two patients requiring readmission (8%): one for febrile urinary tract infection (Clavien-Dindo II) and one child with no JJ stent for urinoma (Clavien-Dindo IIIb). Radiological studies confirmed improvement in dilatation for all cases with no recurrence (median follow-up: 15 mo).

Conclusions

This prospective case series is the first to demonstrate the feasibility and safety of DS in children undergoing R-RALP, obviating the need for routine inpatient care. Excellent results can be achieved by careful patient selection, a clear clinical pathway, and a dedicated team. Further evaluation is warranted to assess the cost effectiveness.

Patient summary

This study shows that day surgery after robotic pyeloplasty is both safe and effective in selected children.

Robotic Surgery in Pediatric Urology: A Critical Appraisal of the GECI and SIVI Consensus of European Experts

Background: This study aimed to create a consensus statement on the indications, applications, and limitations of robotics in pediatric urology. Methods: After a panel and interactive discussion focused on pediatric robotics, a televoting with 10 questions was administered to 100 pediatric surgeons/urologists attending the joint meeting of the French Group of Pediatric Laparoscopy (GECI)/Italian Society of Videosurgery in Infancy (SIVI) in 2021. The results of televoting were analyzed electronically using Mentometer software. Results: Ninety-four percent of participants stated that the cutoff weight for robotics should be >10-15 kg. A minimum of 20-30 procedures should be performed to become confident in robotics (74%). Pediatric urology is the main field of application (73%) and pyeloplasty is the best indication for robotics (63%). Technical problems may happen intraoperatively in 1/10-15 cases (64%). The mean duration of robotic procedures ranges from 150 to 200 minutes (72%). The main drawbacks of robotics are high costs and limited development of miniaturized instruments (74%). Ninety-five percent believed that the costs of robotics may significantly drop with the availability of more robotic brands. The main advantages of robotics over laparoscopy include improved dexterity, easier suturing, and better ergonomics (100%), whereas the main disadvantage of sharing the robot with other specialties is the wearing out of instruments (100%). Conclusions: This is the first consensus statement, endorsed by the GECI and SIVI societies, on the use of robotics in pediatric urology. The need to introduce more robotic brands on the market to lower the costs and to develop miniaturized instruments to be adopted in infants less than 10 kg emerged. Pediatric urology is the main field of application of pediatric robotics, and robotic pyeloplasty is the most common procedure performed. Proctorship is needed for the first 20-30 procedures and technical problems may occur intraoperatively in 1/10-15 cases. The main advantages of robotics over laparoscopy are improved dexterity, easier suturing, and better surgeon ergonomics.

The Potential and the Limitations of Esophageal Robotic Surgery in Children

INTRODUCTION

 There have been numerous reports of robotic pediatric surgery in the literature, particularly regarding urological procedures for school-aged children. Thoracic procedures appear to be less common, despite the fact that encouraging results were reported more than 10 years. Our aim was to report a national experience of esophageal robotic-assisted thoracoscopic surgery (ERATS) and to discuss the most appropriate indications.

MATERIALS AND METHODS

 A retrospective multicenter study was conducted to compile the ERATS performed at five French surgical centers that have been involved in spearheading robotic pediatric surgery over the past 15 years. The data were supplemented by a review of the literature.

RESULTS

 Over the study period, 68 cases of robotic thoracic surgery were performed at the five pediatric centers in question. ERATS was performed for 18 patients (mean age 7.1 years [ ± 5.6]) in four of the centers. These comprised seven esophageal duplications, four esophageal atresias, five Heller's myotomies, and two cases of esophagoplasty. A conversion was needed for two neonates (11%) due to exposure difficulties. Four other procedures for patients who weighed less than 15 kg were successfully completed without causing postoperative complications. In the past 12 years, 22 other cases of ERATS were published worldwide. The indications were the same, except for esophagoplasty, which was not found.

CONCLUSION

 Aside from accessibility issues with the robotic platform, the main limitation is still very much that the low body weight of children results in incompatibility between the size of the trocars and the size of the intercostal space. ERATS is clearly a feasible procedure with technical advantages for most pediatric cases with body weights more than 15 kg. A transdiaphragmatic abdominal approach should be considered for lower esophagus surgery.

Robotic-Assisted Minimally Invasive Surgery in Children

Currently, minimally invasive surgery (MIS) includes conventional laparo-thoracoscopic surgery and robot-assisted surgery (RAS) or robotic surgery. Robotic surgery is performed with robotic devices, for example the Da Vinci system from Intuitive Surgical, which has a miniaturized camera capable of image magnification, a three-dimensional image of the surgical field, and the instruments are articulated with 7 degrees of freedom of movement, and the surgeon operates in a sitting position at a surgical console near the patient. Robotic surgery has gained an enormous surge in use on adults, but it has been slowly accepted for children, although it offers important advantages in complex surgeries. The areas of application of robotic surgery in the pediatric population include urological, general surgery, thoracic, oncological, and otorhinolaryngology, the largest application has been in urological surgery. There is evidence that robotic surgery in children is safe and it is important to offer its benefits. Intraoperative complications are rare, and the frequency of postoperative complications ranges from 0–15%. Recommendations for the implementation of a pediatric robotic surgery program are included. The future will be fascinating with upcoming advancements in robotic surgical systems, the use of artificial intelligence, and digital surgery.

Day-case robot-assisted laparoscopic surgery: Feasibility and safety

OBJECTIVE

The delivery of surgical services has undergone a shift in the past decade with increasing numbers of surgeries being performed in the daycare setting. Implementing a minimally invasive surgical approach with a robot with an enhanced recovery protocol permits robot-assisted laparoscopic surgeries (RALS) to be performed as a day-case (DC) procedure. This study aimed to assess the feasibility and safety of DC surgery according to our experience.

MATERIAL AND METHODS

In this prospective observational study, 43 patients underwent DC RALS performed by a single surgeon over 18 months [simple nephrectomy (n=7), radical nephrectomy (n=15), radical nephrectomy with para-aortic lymphadenectomy (n=5), and adrenalectomy (n=5)]. In addition, reconstructive urological procedures that included pyeloplasty (n=9), ureteroureterostomy (n=1), and bladder diverticulectomy with ureteric re-implantation (n=1) were performed as DC surgeries during this study period. RALS was performed in the standard way with an enhanced recovery pathway of care for DC. We collected data regarding the demographic information, medical comorbidities, preoperative outcomes, intraoperative outcomes, complications, length of stay, and readmission rates. The data were analyzed and evaluated.

RESULTS

All the patients (100%) were successfully discharged on the same day with no major complications (Clavien-Dindo grade>I). The readmission rates were 0%.

CONCLUSION

DC RALS are safe and feasible with an enhanced recovery protocol. With adequate protocols in place, these surgeries might prove to be better than the available minimally invasive techniques and can become the standard of care in the future.

The Financial Burden of Setting up a Pediatric Robotic Surgery Program

Background and Objectives: Robotic surgery is currently at the forefront of both adult and pediatric treatment. The main limit in the wide adoption of this technology is the high cost of purchasing and running the robotic system. This report will focus on the costs assessment of running a robotic program in a pediatric surgery center in Romania. Materials and Methods: In 12 months we performed 40 robot-assisted procedures in children. We recorded and analyzed data regarding their age, gender, pathological condition and comorbidities, surgical procedure, time of surgery, complications, hospital stay and related costs, medication, robotic instruments and consumables, additional cost, and income per case received from the National Insurance Company (NIC). Results: Mean cost per case was €3260.63 (€1880.07 to €9851.78) and was influenced by type of the procedure, intraoperative incidents, postoperative complication, and non-scheduled reinterventions (p < 0.05). The direct costs for operating the surgical robot were relatively constant, regardless of the surgical procedure (mean €1579.81). The reimbursement from the NIC ranged from 5% to 56% (mean 16.9%) of the total cost per case. Conclusion: In Romania, a pediatric surgery robotic program is not cost-efficient and cannot operate relying solely onto the health insurance system.

Considerations regarding pain management and anesthesiological aspects in pediatric patients undergoing minimally invasive surgery: robotic vs laparoscopic-thoracoscopic approach

In the last decade, the applicability of robotic surgery has been demonstrated in many interventions, expanding the indications of minimally invasive surgery also to pediatrics. The aim of the study is to evaluate postoperative pain to demonstrate better control following robotic procedures compared to thoraco-laparoscopic surgery. An observational, retrospective, multicentre study was performed involving 204 children undergoing robot-assisted surgery and thoraco/laparoscopic surgery at the Istituto Giannina Gaslini in Genoa and the Siena University Hospital (2013-2017): 83 children underwent robotic-assisted surgery and 121 thoracic-laparoscopic surgery. Personal data and type of intervention were assessed, dividing the patients into four categories: thoracic, gastrointestinal, hepatobiliary and urological surgeries. We analyzed the anesthetic risk according to ASA classification by type of intervention, the type of anesthesia used, the anesthetic drugs used during surgery and in the postoperative period. Both the problems that occurred during the procedures and the number of interventions converted into open during robotic surgery and laparoscopic thoracic surgery were analyzed. Pain was measured on the 1st, 2nd and 3rd day (FLACC or NRS scales). By comparing the two groups (robotics-non-robotics), the analysis shows that postoperative pain does not change with the chosen approach, but always maintains very low values, typical of minimally invasive surgery. The pain score is significantly higher in patients undergoing thoracic surgery, either robotic or thoracoscopic, compared to those undergoing gastrointestinal surgery (P corrected according to Bonferroni: 0.0006) and those undergoing urological intervention (P corrected according to Bonferroni: 0.04). In conclusion, no significant change in the intensity of postoperative pain between the two groups was found, while it is seen that the pain in patients undergoing thoracic interventions (robotic/thoracoscopic) is more intense than that reported for other types of interventions.

Robot-Assisted Laparoscopic and Thoracoscopic Surgery: Prospective Series of 186 Pediatric Surgeries

Objective: We present the applications and experiences of robot-assisted laparoscopic and thoracoscopic surgery (RALTS) in pediatric surgery. Materials and Methods: A prospective, observational, and longitudinal study was conducted from March 2015 to March 2018 that involved a non-random sample of a pediatric population that was treated with RALTS. The parameters examined were: gender, age, weight, height, diagnoses, surgical technique, elapsed time of console surgery, estimated bleeding, need for hemotransfusion, complications, surgical conversions, postoperative hospital stay, and follow-up. The Clavien-Dindo classification of complications was used. The surgical system used was the da Vinci model, Si version (Intuitive Surgical, Inc., Sunnyvale, CA. U.S.A), with measures of central tendency. Results: In a 36-months period, 186 RALTS cases were performed, in 147 pediatric patients and an adult; 53.23% were male, and the remaining were female. The average age was 83 months, ranging from 3.5 to 204 months, plus one adult patient of 63 years. The stature was an average of 116.6 cm, with a range of 55-185 cm; the average weight was 26.9 kg, with a range of 5-102 kg; the smallest patient at 3.5 months was 55 cm in stature and weighed 5.5 kg. We performed 41 different surgical techniques, grouped in 4 areas: urological 91, gastrointestinal and hepatobiliary (GI-HB) 84, thoracic 6, and oncological 5. The console surgery time was 137.2 min on average, ranging from 10 to 780 min. Surgeon 1 performed 154 operations (82.8%), and the remainder were performed by Surgeon 2, with a conversion rate of 3.76%. The most commonly performed surgeries were: pyeloplasty, fundoplication, diaphragmatic plication, and removal of benign tumors, by area. Hemotransfusion was performed for 4.83%, and complications occurred in 2.68%. The average postoperative stay was 2.58 days, and the average follow-up was 23.5 months. The results of the 4 areas were analyzed in detail. Conclusion: RALTS is safe and effective in children. An enormous variety of surgeries can be safely performed, including complex hepatobiliary, and thoracic surgery in small children. There are few published prospective series describing RALTS in the pediatric population, and most only describe urological surgery. It is important to offer children the advantages and safety of minimal invasion with robotic assistance; however, this procedure has only been slowly accepted and utilized for children. It is possible to implement a robust program of pediatric robotic surgery where multiple procedures are performed.

Implementation of Robotic Surgery in a Pediatric Hospital: Lessons Learned

BACKGROUND

Since the late 1980s, minimally invasive surgery (MIS) has been one of the fastest growing approaches for surgical procedures. However, its development has reached a plateau. One of the reasons is the difficulty to operate on more complex cases, such as neonatal procedures. Some experts report outstanding outcomes for complex operations, but not all surgeons may be able to achieve the same results. Is robotic surgery (RS) a solution?

METHODS

To answer this question, we reviewed the current indications of RS for the pediatric population and the steps needed to incorporate the robotic surgical system in a children's hospital. We reported our experience and presented our first results and the encountered problems.

RESULTS

After a year and a half of experience with RS, several lessons were learned: (1) the current robotic surgical system cannot yet be considered a replacement to conventional MIS, (2) docking is less time consuming than expected, (3) postoperative pain is significantly decreased, (4) the absence of haptic feedback is still a matter of concern, and (5) costs can be afforded by sharing the RS with adult surgeons.

CONCLUSIONS

Based on our experience, the advantages seem to outweigh the drawbacks as it encourages team building and increases overall comfort for the surgeon. However, the current literature fails to prove that RS gives better results for pediatric patients. New advances in technology will probably help to overcome the encountered difficulties and the high costs.

The age of robotic surgery - Is laparoscopy dead?

Introduction

Robot-assisted laparoscopic surgery (RALS) has become a widely used technology in urology. Urological procedures that are now being routinely performed robotically are: radical prostatectomy (RP), radical cystectomy (RC), renal procedures - mainly partial nephrectomy (PN), and pyeloplasty, as well as ureteric re-implantation and adrenalectomy.

Methods

This non-systematic review of the literature examines the effectiveness of RALS compared with conventional laparoscopic surgery for the most relevant urological procedures.

Results

For robot-assisted RP there seems to be an advantage in terms of continence and potency over laparoscopy. Robot-assisted RC seems equal in terms of oncological outcome but with lower complication rates; however, the effect of intracorporeal urinary diversion has hardly been examined. Robotic PN has proven safe and is most likely superior to conventional laparoscopy, whereas there does not seem to be a real advantage for the robot in radical nephrectomy. For reconstructive procedures, e.g. pyeloplasty and ureteric re-implantation, there seems to be advantages in terms of operating time.

Conclusions

We found substantial, albeit mostly low-quality evidence, that robotic operations can have better outcomes than procedures performed laparoscopically. However, in light of the significant costs and because high-quality data from prospective randomised trials are still missing, conventional urological laparoscopy is certainly not 'dead' yet.

Evaluation of Surgical Devices Using an Artificial Pediatric Thoracic Model: A Comparison Between Robot-Assisted Thoracoscopic Suturing Versus Conventional Video-Assisted Thoracoscopic Suturing

BACKGROUND

Pediatric robot-assisted surgery is increasingly being performed, but it is difficult to perform this procedure in infants. A pediatric thoracoscopic model of a 1-year-old patient was developed in our previous study, and this model was used to evaluate the use of a surgical robot for infant surgery.

METHODS

Eight pediatric surgeons performed an intracorporeal suturing and knot-tying task using the da Vinci Xi Robotic Surgical System. The task completion time, number of needle manipulations, and force applied during suturing of the robot-assisted thoracoscopic surgery (RATS) group were compared with those of the video-assisted thoracoscopic surgery (VATS) group whose data had been collected from the same 8 surgeons in our previous study.

RESULTS

The RATS group showed a significantly shorter completion time than the VATS group in the knot-tying phase (P = .016) and in the total phase (P = .0078). The RATS group showed a significantly smaller number of manipulations than the VATS group in the total phase (P = .039). The RATS group showed a significantly smaller pushing force index than the VATS group in the suturing phase (P = .031), knot-tying phase (P = .031), and in the total phase (P = .031). A seventh rib in the model was dislocated in all RATS group cases.

CONCLUSIONS

The da Vinci Surgical System might be useful in infants because of fast movement and small pushing force. However, the robotic 8 mm instruments were too large for use in the thoracic cavity of the 1-year-old infant.

Partial nephrectomy for small children: Robot-assisted versus open surgery

OBJECTIVES

To compare the outcomes of robot-assisted heminephrectomy for duplex kidney in children with those of open heminephrectomy.

METHODS

The present retrospective multicentric analysis reviewed the records of robot-assisted versus open heminephrectomy carried out for duplex kidney in children from 2007 to 2014. Demographic data, weight, surgical time, hospital stay, complications and outcome were recorded. Follow up was based on a clinical review, renal sonography and dimercaptosuccinic acid renal scintigraphy.

RESULTS

A total of 15 patients underwent robot-assisted heminephrectomy, and 13 patients underwent retroperitoneal heminephrectomy by open approach. All patients weighed <15 kg. The mean age at the time of surgery was 20.2 months (range 7-39 months) in the robotic group, and 18.4 months (range 6-41 months) in the open group. The mean hospital stay was statistically longer for the open surgery group (6.3 days, range 5-8 days vs 3.4 days, range 1-7 days; P < 0.001). Regarding postoperative pain control, total morphine equivalent intake was statistically greater for the open group (0.52 mg/kg/day vs 1.08 mg/kg/day; P < 0.001). No patient lost the remaining healthy moiety. There was no significant difference in terms of operating time, complication rate or renal outcomes.

CONCLUSIONS

Robot-assisted heminephrectomy in small children seems to offer comparable renal outcomes with those of its standard open surgery counterpart. Specific technical adjustments are necessary, which typically increase the set-up time.

What are the prospects for non-scheduled robotic procedures in pediatric surgery?

Robotic technology allows for the management of complex surgical cases with a minimally invasive approach. The aim of this study was to communicate our experience using robotic technology for non-scheduled pediatric procedures (NSP). We performed a prospective study over the last 5 years including all consecutive cases where surgery was performed with a robot. NSP procedures were defined as a time to surgery of <24 h. Preoperative time, operative time, overall completion rate, and postoperative course were analyzed. Of the 85 cases recorded, five corresponded to robot-assisted NSP with a mean weight of 10 kg (3-36 kg). The mean time before surgery was 19 h (11-24 h). Conversion rate to open procedure was 40 %. Fifteen NSP had to be performed without robotic plateform. Robotic surgery is a potentially relevant option for most pediatric thoracic or abdominal procedures performed in a non-scheduled setting and offers technical advantages.

A comparative cost analysis of robotic-assisted surgery versus laparoscopic surgery and open surgery: the necessity of investing knowledgeably

BACKGROUND

Robotic surgery has been proposed as a minimally invasive surgical technique with advantages for both surgeons and patients, but is associated with high costs (installation, use and maintenance). The Health Technology Assessment Unit of the Bambino Gesù Children's Hospital sought to investigate the economic sustainability of robotic surgery, having foreseen its impact on the hospital budget METHODS: Break-even and cost-minimization analyses were performed. A deterministic approach for sensitivity analysis was applied by varying the values of parameters between pre-defined ranges in different scenarios to see how the outcomes might differ.

RESULTS

The break-even analysis indicated that at least 349 annual interventions would need to be carried out to reach the break-even point. The cost-minimization analysis showed that robotic surgery was the most expensive procedure among the considered alternatives (in terms of the contribution margin).

CONCLUSIONS

Robotic surgery is a good clinical alternative to laparoscopic and open surgery (for many pediatric operations). However, the costs of robotic procedures are higher than the equivalent laparoscopic and open surgical interventions. Therefore, in the short run, these findings do not seem to support the decision to introduce a robotic system in our hospital.

Bi-Institutional Comparison of Robot-Assisted Laparoscopic Versus Open Ureteroureterostomy in the Pediatric Population

PURPOSE

Ureteroureterostomy (UU) is a useful surgical option for the management of duplication anomalies as well as obstructed single system ureters for children. We aimed to evaluate the safety, efficacy, and outcomes of robot-assisted laparoscopic UU (RALUU) compared with open UU (OUU) in the pediatric population.

PATIENTS AND METHODS

A retrospective review was performed at two institutions including six surgeons' experience with all cases of RALUU and OUU from January 2005 to June 2014. Indications for a surgical procedure included duplex systems with an upper pole ectopic ureter, obstructed ureterocele or lower pole vesicoureteral reflux, and obstruction in a single system. Transureteroureterostomy, laparoscopic UU, and major reconstruction cases where UU was the secondary procedure were excluded.

RESULTS

There were 25 RALUU and 19 OUU cases included. All cases involved duplex systems except two proximal to distal anastomoses in single system obstructed kidneys. RALUUs were more likely to be performed proximally (P = 0.01) and with the use of cystoscopy and stent placement (P = <0.0001). Operative times and estimated blood loss were similar between the two groups. Postoperative complications included four febrile urinary tract infections in each group, one recurrence of nonfebrile urinary tract infection in the open group, and one postoperative obstruction at the ureterovesical junction because of attempted stent placement necessitating nephrostomy tube placement in the open group. This OUU patient was the only one to demonstrate more severe hydronephrosis after surgery on initial follow-up imaging that was again unrelated to the open UU procedure. RALUU had shorter hospital stays by 0.5 days (P = 0.04).

CONCLUSION

Robot-assisted laparoscopic UU is a safe and effective alternative to open UU in children with duplication anomalies and single system obstructed ureters. Operative times and complication rates were comparable with slightly shorter length of hospitalization in robotic cases.

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.

Evaluation of robotic-assisted laparoscopic and open pyeloplasty in children: single-surgeon experience

INTRODUCTION

Robotic-assisted laparoscopic pyeloplasty (RALP), the most commonly undertaken paediatric robotic urologic surgery, has not been compared against open pyeloplasty (OPN) by a single surgeon. Here, we describe our experience and outcomes.

METHODS

Children undergoing RALP or OPN from 2007 to 2013 were reviewed. Clinical success was defined as resolution of presenting symptoms and improved/stable hydronephrosis on ultrasound.

RESULTS

RALP and OPN cohorts comprised 52 and 40 patients, respectively. RALP patients were significantly older (6.8 vs 1.2 years, p<0.01) and heavier (28.4 vs 8.4 kg, p<0.01). Operative times for RALP were longer (203.3 vs 135.0 min, p<0.01), but decreased significantly with increasing experience (r(2)=0.42, p<0.01). Seven type-IIIb Clavien-Dindo complications occurred in RALP patients compared with two in OPN cases. There were no differences in postoperative narcotic administration (p=0.92) or duration of stay in hospital (DOSH) (p=0.93). A total of 11/40 (28%) OPN patients required epidural analgesia but none were placed in the RALP cohort. A total of 49/52 (94%) RALP patients and 40/40 OPN cases had successful outcomes. Three RALP patients required revision RALP.

CONCLUSIONS

These data show that outcomes for RALP and OPN were comparable. An initial learning curve with RALP is to be expected, but operative times for RALP approached those for OPN. Previously reported benefits of RALP (reduced analgesic requirements, DOSH) were not observed. This difference may have been due to comparison of a heterogeneous cohort. Close evaluation of complications allowed for improved placement of stents in RALP.