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Mullin K, Rentea RM, Appleby M, Reeves PT. Gastrointestinal Ostomies in Children: A Primer for the Pediatrician. Pediatr Rev 2024; 45:210-224. [PMID: 38556505 DOI: 10.1542/pir.2023-006195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Despite the advancement of medical therapies in the care of the preterm neonate, in the management of short bowel syndrome and the control of pediatric inflammatory bowel disease, the need to create fecal ostomies remains a common, advantageous treatment option for many medically complex children.
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Affiliation(s)
- Kaitlyn Mullin
- Pediatric Colorectal Center, Department of Pediatrics, Brooke Army Medical Center, San Antonio, TX
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Rebecca M Rentea
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital-Kansas City, Kansas City, MO
- University of Missouri-Kansas City, Kansas City, MO
| | | | - Patrick T Reeves
- Pediatric Colorectal Center, Department of Pediatrics, Brooke Army Medical Center, San Antonio, TX
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD
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Tesoro S, Gamba P, Bertozzi M, Borgogni R, Caramelli F, Cobellis G, Cortese G, Esposito C, Gargano T, Garra R, Mantovani G, Marchesini L, Mencherini S, Messina M, Neba GR, Pelizzo G, Pizzi S, Riccipetitoni G, Simonini A, Tognon C, Lima M. Pediatric robotic surgery: issues in management-expert consensus from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP). Surg Endosc 2022; 36:7877-7897. [PMID: 36121503 PMCID: PMC9613560 DOI: 10.1007/s00464-022-09577-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 07/09/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Pediatric robotic-assisted surgeries have increased in recent years; however, guidance documents are still lacking. This study aimed to develop evidence-based recommendations, or best practice statements when evidence is lacking or inadequate, to assist surgical teams internationally. METHODS A joint consensus taskforce of anesthesiologists and surgeons from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP) have identified critical areas and reviewed the available evidence. The taskforce comprised 21 experts representing the fields of anesthesia (n = 11) and surgery (n = 10) from clinical centers performing pediatric robotic surgery in the Italian cities of Ancona, Bologna, Milan, Naples, Padua, Pavia, Perugia, Rome, Siena, and Verona. Between December 2020 and September 2021, three meetings, two Delphi rounds, and a final consensus conference took place. RESULTS During the first planning meeting, the panel agreed on the specific objectives, the definitions to apply, and precise methodology. The project was structured into three subtopics: (i) preoperative patient assessment and preparation; (ii) intraoperative management (surgical and anesthesiologic); and (iii) postoperative procedures. Within these phases, the panel agreed to address a total of 18 relevant areas, which spanned preoperative patient assessment and patient selection, anesthesiology, critical care medicine, respiratory care, prevention of postoperative nausea and vomiting, and pain management. CONCLUSION Collaboration among surgeons and anesthesiologists will be increasingly important for achieving safe and effective RAS procedures. These recommendations will provide a review for those who already have relevant experience and should be particularly useful for those starting a new program.
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Affiliation(s)
- Simonetta Tesoro
- Division of Anesthesia, Analgesia, and Intensive Care, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Piergiorgio Gamba
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, 35128, Padua, Italy.
| | - Mirko Bertozzi
- Department of Pediatric Surgery, IRCCS San Matteo Polyclinic, University of Pavia, Pavia, Italy
| | - Rachele Borgogni
- Pediatric Surgery Unit, Federico II University of Naples, Naples, Italy
| | - Fabio Caramelli
- Anesthesia and Intensive Care Unit, IRCCS Sant'Orsola Polyclinic, Bologna, Italy
| | - Giovanni Cobellis
- Pediatric Surgery Unit, Salesi Children's Hospital, Polytechnical University of Marche, Ancona, Italy
| | - Giuseppe Cortese
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University of Naples, Naples, Italy
| | - Ciro Esposito
- Pediatric Surgery Unit, Federico II University of Naples, Naples, Italy
| | - Tommaso Gargano
- Pediatric Surgery Unit, IRCCS Policlinico Sant'Orsola, University of Bologna, Bologna, Italy
| | - Rossella Garra
- Institute of Anesthesia and Intensive Care, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Giulia Mantovani
- Pediatric Anesthesia, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Laura Marchesini
- Division of Anesthesia, Analgesia, and Intensive Care, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Simonetta Mencherini
- Anesthesiology and Intensive Care Unit, Fondazione IRCCS San Matteo Polyclinic, Pavia, Italy
| | - Mario Messina
- Division of Pediatric Surgery, Santa Maria Alle Scotte Polyclinic, University of Siena, Siena, Italy
| | - Gerald Rogan Neba
- Department of Pediatric Anesthesia and Intensive Care, Salesi Children's Hospital, Ancona, Italy
| | - Gloria Pelizzo
- Pediatric Surgery Department, Vittore Buzzi' Children's Hospital, Milan, Italy
- Department of Biomedical and Clinical Science, University of Milan, Milan, Italy
| | - Simone Pizzi
- Department of Pediatric Anesthesia and Intensive Care, Salesi Children's Hospital, Ancona, Italy
| | - Giovanna Riccipetitoni
- Department of Pediatric Surgery, IRCCS San Matteo Polyclinic, University of Pavia, Pavia, Italy
| | - Alessandro Simonini
- Department of Pediatric Anesthesia and Intensive Care, Salesi Children's Hospital, Ancona, Italy
| | - Costanza Tognon
- Pediatric Anesthesia, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Mario Lima
- Pediatric Surgery Unit, IRCCS Policlinico Sant'Orsola, University of Bologna, Bologna, Italy
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Cserni T, Urban D, Hajnal D, Erces D, Varga G, Nagy A, Cserni M, Marei M, Hennayake S, Kubiak R. Pyeloureteric magnetic anastomosis device to simplify laparoscopic pyeloplasty: a proof-of-concept study. BJU Int 2020; 127:409-411. [PMID: 33220114 DOI: 10.1111/bju.15301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Tamas Cserni
- The Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Institute of Surgical Research, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Daniel Urban
- Institute of Surgical Research, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Daniel Hajnal
- Institute of Surgical Research, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Daniel Erces
- Institute of Surgical Research, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Gabriella Varga
- Institute of Surgical Research, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Andras Nagy
- Department of Radiology, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Marton Cserni
- Faculty of Mechanical Engineering, Budapest University of Technology and Economics, Budapest, Hungary
| | - Mahmoud Marei
- The Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Faculty of Medicine (Kasr Alainy), Department of Pediatric Surgery, Cairo University Children's Hospitals, Cairo University, Cairo, Egypt
| | - Supul Hennayake
- The Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Rainer Kubiak
- Department of Pediatric Surgery, Medical Faculty Mannheim (UMM), University of Heidelberg, Mannheim, Germany
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Kawal T, Srinivasan AK, Chang J, Long C, Chu D, Shukla AR. Robotic-assisted laparoscopic ureteral re-implant (RALUR): Can post-operative urinary retention be predicted? J Pediatr Urol 2018; 14:323.e1-323.e5. [PMID: 29954664 DOI: 10.1016/j.jpurol.2018.05.010] [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: 01/12/2018] [Accepted: 05/15/2018] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Urinary retention following robotic-assisted laparoscopic extravesical ureteral reimplantation (RALUR) is proposed to be due to traction or injury of the pelvic parasympathetic nerve plexus during distal ureteral dissection. Nerve-sparing techniques have been employed to avoid injury to the pelvic plexus, either directly or indirectly. This single-center study assessed postoperative urinary retention rates after extravesical RALUR and investigated whether demographic or operative factors could predict this occurrence. METHODS All RALUR cases entered into an Institutional Review Board-approved registry were retrospectively reviewed, and the rate of postoperative retention was determined. Postoperative urinary retention was defined as the need for catheterization at any time in the postoperative period during hospital admission or within 1 week after the operation. This included acute urinary retention episodes (AUR) as well as high post-void residuals (>50% of expected bladder capacity). Univariate analysis was performed to analyze for predictors of postoperative retention. Factors assessed included age, gender, clinical presentation, bowel bladder dysfunction (BBD), pre-operative urinary tract infection (UTI), procedure length, grade of vesicoureteral reflux (VUR), and operative laterality. RESULTS A total of 128 patients underwent extravesical RALUR in 179 ureters during the study period 2012-2016. Male:female ratio was 1:2.6. Median age at surgery was 4 years. Bilateral RALUR was performed in 52 cases (40.6%), and unilateral in 76 (59.4%). Urinary retention requiring catheterization occurred in 11 cases (8.59%). Of these, seven were post-bilateral RALUR, while the remaining four were unilateral. In seven cases, postoperative retention occurred within 24 h following RALUR. The remaining four instances occurred within 1 week, despite successful voiding in the immediate postoperative period. Univariate analysis revealed male gender (P = 0.009) and operating room time (P = 0.029) as predictors of retention. No association was found with age, weight, BBD, pre-operative UTI, grade of VUR, or laterality. CONCLUSION Urinary retention after RALUR was an infrequent complication. When it did occur, urinary retention appeared to be secondary to covariates such as male gender and length of surgical time - possibly an indication of technical difficulty - rather than laterality of repair.
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Affiliation(s)
- T Kawal
- Pediatric Urology Department, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - A K Srinivasan
- Pediatric Urology Department, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J Chang
- Pediatric Urology Department, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - C Long
- Pediatric Urology Department, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - D Chu
- Pediatric Urology Department, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - A R Shukla
- Pediatric Urology Department, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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5
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The age of robotic surgery - Is laparoscopy dead? Arab J Urol 2018; 16:262-269. [PMID: 30140462 PMCID: PMC6104663 DOI: 10.1016/j.aju.2018.07.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 06/24/2018] [Accepted: 07/10/2018] [Indexed: 01/06/2023] Open
Abstract
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.
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Key Words
- (RA)PN, (robot-assisted) partial nephrectomy
- (RA)RN, (robot-assisted) radical nephrectomy
- (RA)RP, (robot-assisted) radical prostatectomy
- (RA-)RPLND, (robot-assisted) retroperitoneal lymphadenectomy (RA)RC, (robot-assisted) radical cystectomy
- 3D, three-dimensional
- EAU, European Association of Urology
- ICG, indocyanine green
- IVC, inferior vena cava
- Laparoscopic
- NSGCT, non-seminomatous germ cell tumour
- PSM, positive surgical margin
- RAIL, robot-assisted inguinal lymphadenectomy
- RALS, robot-assisted laparoscopic surgery
- RALUR, robot-assisted laparoscopic ureteric re-implantation
- Robotic
- Robotic urological surgery
- Robotic-assisted radical prostatectomy
- WIT, warm ischaemia time
- dVSS, da Vinci Surgical System
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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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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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Smith PH, Carpenter M, Herbst KW, Kim C. Milestone assessment of minimally invasive surgery in Pediatric Urology fellowship programs. J Pediatr Urol 2017; 13:110.e1-110.e6. [PMID: 27697470 DOI: 10.1016/j.jpurol.2016.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 08/02/2016] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Minimally invasive surgery has become an important aspect of Pediatric Urology fellowship training. In 2014, the Accreditation Council for Graduate Medical Education published the Pediatric Urology Milestone Project as a metric of fellow proficiency in multiple facets of training, including laparoscopic/robotic procedures. OBJECTIVE The present study assessed trends in minimally invasive surgery training and utilization of the Milestones among recent Pediatric Urology fellows. STUDY DESIGN Using an electronic survey instrument, Pediatric Urology fellowship program directors and fellows who completed their clinical year in 2015 were surveyed. Participants were queried regarding familiarity with the Milestone Project, utilization of the Milestones, robotic/laparoscopic case volume and training experience, and perceived competency with robotic/laparoscopic surgery at the start and end of the fellowship clinical year according to Milestone criteria. Responses were accepted between August and November 2015. RESULTS Surveys were distributed via e-mail to 35 fellows and 30 program directors. Sixteen fellows (46%) and 14 (47%) program directors responded. All fellows reported some robotic experience prior to fellowship, and 69% performed >50 robotic/laparoscopic surgeries during residency. Fellow robotic/laparoscopic case volume varied: three had 1-10 cases (19%), four had 11-20 cases (25%), and nine had >20 cases (56%). Supplementary or robotic training modalities included simulation (9), animal models (6), surgical videos (7), and courses (2). Comparison of beginning and end of fellowship robotic/laparoscopic Milestone assessment (Summary Fig.) revealed scores of <3 in (10) 62% of fellow self-assessments and 10 (75%) of program director assessments. End of training Milestone scores >4 were seen in 12 (75%) of fellow self-assessment and eight (57%) of program director assessments. DISCUSSION An improvement in robotic/laparoscopic Milestone scores by both fellow self-assessment and program director assessment was observed during the course of training; however, 43% of program directors rated their fellow below the graduation target of a Milestone score of 4. CONCLUSION The best ways to teach minimally invasive surgery in fellowship training must be critically considered.
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Affiliation(s)
- P H Smith
- Division of Urology, Connecticut Children's Medical Center, Hartford, CT, USA; University of Connecticut School of Medicine, Farmington, CT, USA.
| | - M Carpenter
- Division of Urology, Connecticut Children's Medical Center, Hartford, CT, USA; Department of Research, Connecticut Children's Medical Center, Hartford, CT, USA
| | - K W Herbst
- Division of Urology, Connecticut Children's Medical Center, Hartford, CT, USA; Department of Research, Connecticut Children's Medical Center, Hartford, CT, USA
| | - C Kim
- Division of Urology, Connecticut Children's Medical Center, Hartford, CT, USA; University of Connecticut School of Medicine, Farmington, CT, USA
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Mizuno K, Kojima Y, Kurokawa S, Kamisawa H, Nishio H, Moritoki Y, Nakane A, Maruyama T, Okada A, Kawai N, Tozawa K, Kohri K, Yasui T, Hayashi Y. Robot-assisted laparoscopic pyeloplasty for ureteropelvic junction obstruction: comparison between pediatric and adult patients-Japanese series. J Robot Surg 2016; 11:151-157. [DOI: 10.1007/s11701-016-0633-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 07/23/2016] [Indexed: 01/19/2023]
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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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Harel M, Herbst KW, Silvis R, Makari JH, Ferrer FA, Kim C. Objective pain assessment after ureteral reimplantation: comparison of open versus robotic approach. J Pediatr Urol 2015; 11:82.e1-8. [PMID: 25864615 DOI: 10.1016/j.jpurol.2014.12.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 12/18/2014] [Indexed: 12/26/2022]
Abstract
INTRODUCTION While open ureteral reimplantation is the gold standard of surgical intervention for vesicoureteral reflux (VUR), minimally invasive approaches offer the potential benefits of decreased postoperative pain, improved cosmesis, and shorter hospital stay and convalescence. Studies comparing open and minimally invasive surgery with respect to postoperative pain in children have been inconclusive. OBJECTIVE We sought to compare postoperative pain in children undergoing open versus robotic ureteral reimplantation by using age-appropriate, validated pain assessment scales. METHODS A prospective cohort of all patients enrolled in an Institutional Review Board-approved VUR surgery registry between July 2010 and February 2013 was analyzed. Patients who underwent endoscopic treatment or who received caudal or epidural anesthesia were excluded. Age-appropriate, validated pain scales ranging from 0 to 10 were utilized for pain assessment. Pain scores and narcotic doses administered on the first postoperative day were analyzed. RESULTS Of the 34 subjects included, 11 underwent open intravesical reimplantation, while 23 patients underwent robotic extravesical reimplantation. Table 1 displays patient characteristics and results of pain assessment. Robotic surgery was associated with lower narcotic requirement compared to open surgery (P < 0.05). The difference in pain scores between the two cohorts approached, but did not reach, statistical significance (P = 0.12). However, the percentage of patients with mild or no pain (57% robotic, 27% open) versus severe pain (9% robotic, 45% open) was notably different between the two cohorts. DISCUSSION Previous studies addressing the effect of surgical modality on pediatric postoperative pain are limited by their reliance on narcotic administration as an indirect surrogate for measuring pain. In the present study, postoperative pain was assessed with narcotic requirements and consistently collected validated pain scores, which more accurately reflect a patient's perceived pain. Although there was no significant difference in subjective pain scores between patients undergoing open versus robotic reimplantation, the percentage of patients with mild or no pain (57% robotic, 27% open) versus severe pain (9% robotic, 45% open) was notably different between the two cohorts. This study was limited by a lack of randomization as well as small sample size, which did not allow for age sub-group analysis or small differences to be statistically significant. CONCLUSIONS In the present study, robotic ureteral reimplantation was associated with lower narcotic requirement compared to open surgery, and lower intensity of postoperative pain according to a direct pain assessment tool. Larger sample sizes are necessary to strengthen statistical comparisons.
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Affiliation(s)
- M Harel
- University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030, USA; Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, USA.
| | - K W Herbst
- Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, USA.
| | - R Silvis
- Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, USA.
| | - J H Makari
- University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030, USA; Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, USA.
| | - F A Ferrer
- University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030, USA; Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, USA.
| | - C Kim
- University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030, USA; Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, USA.
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Murthy P, Cohn JA, Gundeti MS. Evaluation of robotic-assisted laparoscopic and open pyeloplasty in children: single-surgeon experience. Ann R Coll Surg Engl 2015; 97:109-14. [PMID: 25723686 PMCID: PMC4473386 DOI: 10.1308/003588414x14055925058797] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2014] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- P Murthy
- University of Chicago Medical Center, Section of Urology, USA
| | - JA Cohn
- University of Chicago Medical Center, Section of Urology, USA
| | - MS Gundeti
- University of Chicago Medical Center, Section of Urology, USA
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14
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Dalela D, Ahlawat R, Sood A, Jeong W, Bhandari M, Menon M. The growth of computer-assisted (robotic) surgery in urology 2000-2014: The role of Asian surgeons. Asian J Urol 2015; 2:1-10. [PMID: 29264114 PMCID: PMC5730690 DOI: 10.1016/j.ajur.2014.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 08/28/2014] [Accepted: 09/06/2014] [Indexed: 11/25/2022] Open
Abstract
Objective A major role in the establishment of computer-assisted robotic surgery (CARS) can be traced to the work of Mani Menon at Vattikuti Urology Institute (VUI), and of many surgeons of Asian origin. The success of robotic surgery in urology has spurred its acceptance in other surgical disciplines, improving patient comfort and disease outcomes and helping the industrial growth. The present paper gives an overview of the progress and development of robotic surgery, especially in the field of Urology; and to underscore some of the seminal work done by the VUI and Asian surgeons in the development of robotic surgery in urology in the US and around the world. Methods PubMed/Medline and Scopus databases were searched for publications from 2000 through June 2014, using algorithms based on keywords “robotic surgery”, ”prostate”, “kidney”, “adrenal”, “bladder”, “reconstruction”, and “kidney transplant”. Inclusion criteria used were published full articles, book chapters, clinical trials, prospective and retrospective series, and systematic reviews/meta-analyses written in English language. Studies from Asian institutions or with the first/senior author of Asian origin were included for discussion, and focused on techniques of robotic surgery, relevant patient outcomes and associated demographic trends. Results A total of 58 articles selected for final review highlight the important strides made by robots in urology, from robotic radical prostatectomy in 2000 to robotic kidney transplant in 2014. In the hands of an experienced robotic surgeon, it has been demonstrated to improve functional patient outcomes and minimize perioperative complications compared to open surgery, especially in urologic oncology and reconstructive urology. With increasing surgeon proficiency, the benefits of robotic surgery were consistently seen across different surgical disciplines, patient populations, and strata. Conclusion The addition of robot to the surgical armamentarium has allowed better patient care and improved disease outcomes. VUI and surgeons of Asian origin have played a pioneering role in dissemination of computer-assisted surgery.
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Affiliation(s)
- Deepansh Dalela
- Henry Ford Health System - Vattikuti Urology Institute, Detroit, MI, USA
| | - Rajesh Ahlawat
- Medanta Hospitals - Medanta Vattikuti Urology Institute, Gurgaon, Haryana, India
| | - Akshay Sood
- Henry Ford Health System - Vattikuti Urology Institute, Detroit, MI, USA
| | - Wooju Jeong
- Henry Ford Health System - Vattikuti Urology Institute, Detroit, MI, USA
| | - Mahendra Bhandari
- Henry Ford Health System - Vattikuti Urology Institute, Detroit, MI, USA
| | - Mani Menon
- Henry Ford Health System - Vattikuti Urology Institute, Detroit, MI, USA
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Dalela D, Ahlawat R, Sood A, Jeong W, Bhandari M, Menon M. WITHDRAWN: The growth of computer-assisted (robotic) surgery in urology 2000–2014: The role of Asian surgeons. Asian J Urol 2014. [DOI: 10.1016/j.ajur.2014.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Akhavan A, Avery D, Lendvay TS. Robot-assisted extravesical ureteral reimplantation: outcomes and conclusions from 78 ureters. J Pediatr Urol 2014; 10:864-8. [PMID: 24642080 DOI: 10.1016/j.jpurol.2014.01.028] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Accepted: 01/28/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Extravesical robot-assisted laparoscopic ureteral reimplantation (RALUR) is a popular alternative to open surgery. We report our experience with RALUR and evaluate clinical variables as predictors for failure. METHODS We retrospectively evaluated the records of patients who underwent RALUR by a single surgeon for treatment of primary vesicoureteral reflux. Clinical and demographic variables were determined. Clinical variables were compared with surgical outcomes using the Student two-tailed type 2 t test. RESULTS Fifty patients underwent a combined 78 extravesical RALURs. Median (range) age was 6.2 (1.9-18.0) years; median (range) preoperative reflux grade was 3 (0-5). Dysfunctional elimination syndrome (DES) was present in 32 (64%). Ten (20%) patients had prior deflux, and two (4%) had prior ureteroneocystostomy on the ipsilateral side. Postoperative cystogram was performed in 100% at a median (range) of 55 (27-133) days. Median (range) follow-up was 286 (27-2238) days. Febrile urinary tract infection occurred in five (10%), none of whom had reflux on initial follow-up postoperative cystogram. All five had a history of DES and were female. Six complications occurred in five (10%) patients, including ileus (2), ureteral obstruction (2), ureteral injury (1), and perinephric fluid collection (1). Transient urinary retention occurred in one. Five of 22 (22.7%) patients undergoing unilateral surgery had contralateral de novo reflux. Six of 78 ureters (7.7%) had persistent reflux postoperatively. Neither persistent nor de novo reflux was associated with any of the clinical variables assessed. CONCLUSIONS RALUR is an effective and safe option for patients with primary vesicoureteral reflux requiring surgery.
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Affiliation(s)
- Ardavan Akhavan
- Division of Pediatric Urology, Seattle Children's Hospital, 4800 Sand Point Way, NE, Seattle, WA 98105, USA
| | - Daniel Avery
- Division of Pediatric Urology, Seattle Children's Hospital, 4800 Sand Point Way, NE, Seattle, WA 98105, USA
| | - Thomas S Lendvay
- Division of Pediatric Urology, Seattle Children's Hospital, 4800 Sand Point Way, NE, Seattle, WA 98105, USA.
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Bansal D, Cost NG, Bean CM, Vanderbrink BA, Schulte M, Noh PH. Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery. J Pediatr Urol 2014; 10:869-74. [PMID: 24661900 DOI: 10.1016/j.jpurol.2014.01.029] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Accepted: 01/24/2014] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Our aim was to assess the outcomes of infant robot-assisted laparoscopic (RAL) upper urinary tract reconstruction. MATERIALS AND METHODS The medical records of all infants who underwent RAL upper urinary tract reconstruction were reviewed. Patients less than 1 year of age at surgery were included. Patient demographics, intraoperative details, narcotic usage, and complications were reviewed. RESULTS Ten infants met the study criteria. There were five right and five left-sided procedures. Eight pyeloplasties (4 right, 4 left) and two ureteroureterostomies (1 right single system, 1 left duplex system) were performed. The median age was 8 months (range 3-12 months). Median weight was 7.7 kg (range 5.8-10.9 kg). Median operative time was 128 min (range 95-205 min). There was no significant blood loss or intraoperative complications. One (10%) patient received a regional block. Eight (80%) patients did not receive postoperative narcotics. Median hospital stay was 1 day (range 1-2). Median follow-up was 10 months (range 3-18 months). Complications included one urinary leak, one ileus, and one urinary tract infection. Hydronephrosis improved in all patients. CONCLUSIONS Infant RAL upper urinary tract reconstruction is technically feasible, safe, and effective. It can be applied for duplication anomalies and single system obstructions in infants.
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Affiliation(s)
- Danesh Bansal
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 5037, Cincinnati, OH 45229, USA
| | - Nicholas G Cost
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 5037, Cincinnati, OH 45229, USA
| | - Christopher M Bean
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 5037, Cincinnati, OH 45229, USA
| | - Brian A Vanderbrink
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 5037, Cincinnati, OH 45229, USA
| | - Marion Schulte
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 5037, Cincinnati, OH 45229, USA
| | - Paul H Noh
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 5037, Cincinnati, OH 45229, USA.
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Blanc T, Koulouris E, Botto N, Paye-Jaouen A, El-Ghoneimi A. Laparoscopic pyeloplasty in children with horseshoe kidney. J Urol 2013; 191:1097-103. [PMID: 24140844 DOI: 10.1016/j.juro.2013.10.059] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2013] [Indexed: 12/17/2022]
Abstract
PURPOSE Laparoscopic pyeloplasty for ureteropelvic junction obstruction associated with horseshoe kidney has been described in adults but seldom in young children. We describe our experience in 10 children treated successfully with laparoscopic dismembered pyeloplasty. MATERIALS AND METHODS Eight boys and 2 girls with a mean age of 8 years (range 0.7 to 16.5) underwent laparoscopic dismembered pyeloplasty for ureteropelvic junction obstruction associated with horseshoe kidney between 2002 and 2012. Presenting symptoms were abdominal pain (3 patients), urinary tract infection (2), abdominal mass (1) and hematuria (1). Horseshoe kidney was diagnosed preoperatively in all cases but 1. The anastomosis was done by running or interrupted 5-zero or 6-zero resorbable sutures and drained by a Double-J® stent. RESULTS Laparoscopic dismembered pyeloplasty was feasible in all cases. Mean operating time was 220 minutes (range 180 to 260). Anatomical abnormalities included anteriorly crossing vessels at the ureteropelvic junction in 6 cases (polar vessels in 4, ureteropelvic junction posterior to an abnormal branch of vena cava in 1 and renal vein in 1) and high ureteral insertion in 4. Two children underwent an extensive reduction pyeloplasty. Mean hospital stay was 3.2 days (range 1 to 8). Mean followup was 50 months (range 4 to 132). All patients were asymptomatic with significant improvement of dilatation. CONCLUSIONS The transperitoneal laparoscopic approach is adapted for pyeloplasty in children with horseshoe kidney. This procedure allows global exploration of the upper tract and efficient identification of anatomical anomalies, especially crossing vessels. Although our series is small, it is the first known description specific to horseshoe kidney in children and demonstrates that this approach has lasting effectiveness in young children.
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Affiliation(s)
- Thomas Blanc
- Department of Pediatric Surgery and Urology, Robert Debré University Hospital, AP-HP Université Paris Diderot, Sorbonne Paris Cité, Paris and Department of Pediatric Surgery, Centre Hospitalier Saint Denis, Saint-Denis (EK), France
| | - Efstathia Koulouris
- Department of Pediatric Surgery and Urology, Robert Debré University Hospital, AP-HP Université Paris Diderot, Sorbonne Paris Cité, Paris and Department of Pediatric Surgery, Centre Hospitalier Saint Denis, Saint-Denis (EK), France
| | - Nathalie Botto
- Department of Pediatric Surgery and Urology, Robert Debré University Hospital, AP-HP Université Paris Diderot, Sorbonne Paris Cité, Paris and Department of Pediatric Surgery, Centre Hospitalier Saint Denis, Saint-Denis (EK), France
| | - Annabel Paye-Jaouen
- Department of Pediatric Surgery and Urology, Robert Debré University Hospital, AP-HP Université Paris Diderot, Sorbonne Paris Cité, Paris and Department of Pediatric Surgery, Centre Hospitalier Saint Denis, Saint-Denis (EK), France
| | - Alaa El-Ghoneimi
- Department of Pediatric Surgery and Urology, Robert Debré University Hospital, AP-HP Université Paris Diderot, Sorbonne Paris Cité, Paris and Department of Pediatric Surgery, Centre Hospitalier Saint Denis, Saint-Denis (EK), France.
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