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Gnech M, 't Hoen L, Zachou A, Bogaert G, Castagnetti M, O'Kelly F, Quaedackers J, Rawashdeh YF, Silay MS, Kennedy U, Skott M, van Uitert A, Yuan Y, Radmayr C, Burgu B. Update and Summary of the European Association of Urology/European Society of Paediatric Urology Paediatric Guidelines on Vesicoureteral Reflux in Children. Eur Urol 2024; 85:433-442. [PMID: 38182493 DOI: 10.1016/j.eururo.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/05/2023] [Accepted: 12/13/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND AND OBJECTIVE The prescriptive literature on vesicoureteral reflux (VUR) is still limited and thus the level of evidence is generally low. The aim of these guidelines is to provide a practical approach to the treatment of VUR that is based on risk analysis and selective indications for both diagnostic tests and interventions. We provide a 2023 update on the chapter on VUR in children from the European Association of Urology (EAU) and European Society for Paediatric Urology (ESPU) guidelines. METHODS A structured literature review was performed for all relevant publications published from the last update up to March 2022. KEY FINDINGS AND LIMITATIONS The most important updates are as follows. Bladder and bowel dysfunction (BBD) is common in toilet-trained children presenting with urinary tract infection (UTI) with or without primary VUR and increases the risk of febrile UTI and focal uptake defects on a radionuclide scan. Continuous antibiotic prophylaxis (CAP) may not be required in every VUR patient. Although the literature does not provide any reliable information on CAP duration in VUR patients, a practical approach would be to consider CAP until there is no further BBD. Recommendations for children with febrile UTI and high-grade VUR include initial medical treatment, with surgical care reserved for CAP noncompliance, breakthrough febrile UTIs despite CAP, and symptomatic VUR that persists during long-term follow-up. Comparison of laparoscopic extravesical versus transvesicoscopic ureteral reimplantation demonstrated that both are good option in terms of resolution and complication rates. Extravesical surgery is the most common approach used for robotic reimplantation, with a wide range of variations and success rates. CONCLUSIONS AND CLINICAL IMPLICATIONS This summary of the updated 2023 EAU/ESPU guidelines provides practical considerations for the management and diagnostic evaluation of VUR in children. ADVANCING PRACTICE For children with VUR, it is important to treat BBD if present. A practical approach regarding the duration of CAP is to consider administration until BBD resolution. PATIENT SUMMARY We provide a summary and update of guidelines on the diagnosis and management of urinary reflux (where urine flows back up through the urinary tract) in children. Treatment of bladder and bowel dysfunction is critical, as this is common in toilet-trained children presenting with urinary tract infection.
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Affiliation(s)
- Michele Gnech
- Department of Paediatric Urology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.
| | - Lisette 't Hoen
- Department of Pediatric Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Alexandra Zachou
- Department of HIV and Sexual Health, Chelsea & Westminster Hospital, London, UK
| | - Guy Bogaert
- Department of Urology, University of Leuven, Leuven, Belgium
| | - Marco Castagnetti
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padua, Italy
| | - Fardod O'Kelly
- Division of Paediatric Urology, Beacon Hospital Dublin & University College Dublin, Ireland
| | - Josine Quaedackers
- Department of Urology, University Medical Center Groningen, Groningen, The Netherlands
| | - Yazan F Rawashdeh
- Department of Urology, Section of Pediatric Urology, Aarhus University Hospital, Aarhus, Denmark
| | - Mesrur Selcuk Silay
- Division of Pediatric Urology, Department of Urology, Biruni University, Istanbul, Turkey
| | - Uchenna Kennedy
- Department of Pediatric Urology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Martin Skott
- Department of Urology, Section of Pediatric Urology, Aarhus University Hospital, Aarhus, Denmark
| | - Allon van Uitert
- Department of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Yuhong Yuan
- Department of Medicine, London Health Science Centre, London, Ontario, Canada, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Christian Radmayr
- Department of Urology, Medical University of Innsbruck, Innsbruck, Austria
| | - Berk Burgu
- Department of Pediatric Urology, Ankara University School of Medicine, Ankara, Turkey
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Koga H, Murakami H, Seo S, Ochi T, Nakamura H, Miyake Y, Kosaka S, Takeda M, Fujiwara N, Arii R, Tsuboi K, Lane GJ, Yamataka A. Retroperitoneoscopic Pyeloplasty for Ureteropelvic Junction Obstruction in Children: Value of Robotic Assistance. J Pediatr Surg 2023; 58:1291-1295. [PMID: 36935228 DOI: 10.1016/j.jpedsurg.2023.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/14/2023] [Indexed: 02/19/2023]
Abstract
AIM Retroperitoneal pyeloplasty (RP) for pediatric ureteropelvic junction obstruction (UPJO) performed using retroperitoneoscopy (retro-RP) or robotic assistance (robo-RP) were compared. METHODS All subjects were Japanese, matched for age, weight, and RP diameters. All RP were performed in the lateral decubitus position at a single institute by the same team using identical protocols. Five independent surgeons were asked to score intraoperative video recordings for perceived difficulty of suturing (DOS; 5 = impossible; 4 = difficult; 3 = tedious; 2 = slow; 1 = easy) and rank RP as +1 if robo-RP appeared to be superior, 0 if they appeared to be the same, and -1 if robo-RP appeared to be inferior. RESULTS Robo-RP performed 2018-2022 (n = 22) were matched with retro-RP performed 2011-2019 (n = 34). Mean overall operative times were similar (robo-RP: 305.2 ± 57.8 min versus retro-RP: 340.0 ± 117.9 min; p = 0.19), but securing the larger retroperitoneal space required for robo-RP took significantly longer; 50.8 ± 13.9 min versus 24.3 ± 9.6 min; p < 0.0001. Total anastomotic time (TAT) and TAT per suture were both significantly shorter for robo-RP (p < 0.0001). The coefficient of variation for time taken to place one suture was smaller for robo-RP than for retro-RP. DOS was lower for robo-RP with less variance (p < 0.01). Robo-RP had shorter drainage tube insertion, ambulated quicker postoperatively, and shorter hospitalization. Retro-RP had anastomotic complications; leaks (n = 2) and strictures (n = 2, requiring conventional open re-pyeloplasty). Robo-RP had no anastomotic complications and was ranked +1 unanimously. CONCLUSIONS The RP anastomosis was quicker with less complications and more precise with robotic assistance in matched patients under similar circumstances. Should RP be indicated, robo-RP is recommended. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Hiroyuki Koga
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan.
| | - Hiroshi Murakami
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Shogo Seo
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Takanori Ochi
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroki Nakamura
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yuichiro Miyake
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Seitaro Kosaka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Masahiro Takeda
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Naho Fujiwara
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Rumi Arii
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Koichi Tsuboi
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Geoffrey J Lane
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
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Laparoscopic versus robot-assisted pyeloplasty in infants and young children. Asian J Surg 2023; 46:868-873. [PMID: 36192267 DOI: 10.1016/j.asjsur.2022.09.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/22/2022] [Accepted: 09/11/2022] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE To compare the characteristics of conventional laparoscopic pyeloplasty (LP) and robotic-assisted laparoscopic pyeloplasty (RALP) in infants and young children with ureteropelvic junction obstruction (UPJO). METHODS We performed a retrospective study of patients (age: 0-36 months) who underwent dismembered pyeloplasty (Anderson-Hynes) with the fourth-generation RALP or traditional LP between April 2020 and December 2020. RESULTS A total of 33 patients with UPJO were enrolled: 12 underwent RALP (9 left side; 3 right side) and 21 underwent LP (18 left side; 3 right side). In the RALP group, the median patient age was 17 months (range: 5-36 months). In the LP group, the median patient age was 9 months (range: 2-36 months) (P = 0.182). The mean operation times were 120.25 ± 37.54 min (RALP) and 156.10 ± 51.11 min (LP) (P = 0.042), and the mean lengths of hospital stay were 6.42 ± 1.62 days (RALP) and 8.19 ± 2.25 days (LP) (P = 0.023). Removal of the drainage tube was performed after 3.08 ± 0.69 days (RALP) and after 4.76 ± 1.81 days (LP) (P = 0.001). The postoperative pain showed no significant difference. The mean hospitalization costs were 61464.75 ± 2800.53 yuan (RALP) and 22169.52 ± 3442.15 yuan (LP) (P < 0.001). The mean follow-up time was 10-18 months. Significant improvements in the anteroposterior diameter and parenchymal thickness were observed after surgery. Conversion to laparotomy was not performed. No short-term complications occurred during postoperative hospitalization and follow-up. CONCLUSION RALP has the advantages of less trauma and faster recovery. It can be safely and effectively performed in infants and young children, and its effectiveness is similar to that of traditional LP.
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Vauth F, Zöhrer P, Girtner F, Rösch WH, Hofmann A. Open Pyeloplasty in Infants under 1 Year-Proven or Meaningless? CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020257. [PMID: 36832385 PMCID: PMC9955854 DOI: 10.3390/children10020257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/28/2023] [Accepted: 01/29/2023] [Indexed: 02/01/2023]
Abstract
The use of minimally invasive surgery (MIS) to treat ureteropelvic junction obstruction (UPJO) in children has significantly increased. Nowadays, open pyeloplasty (OP) seems to lose importance. The aim of this study is to evaluate the safety and efficacy of OP in infants < 1 year. Medical records of patients < 1 year with UPJO who had undergone retroperitoneal OP (January 2008-February 2022) at our institution were retrospectively analyzed. Included patients were operated on according to a modified Anderson-Hynes technique. All clinical, operative, and postoperative (1 month-5 years' follow-up) data were collected. Additionally, a nonvalidated questionnaire was sent to the patients/parents. A total of 162 infants (124 boys) met the inclusion criteria. The median age at surgery was 3 months (range: 0-11 months). The median operation time was 106 min (range: 63-198 min). None of the patients had severe surgical complication (Clavien-Dindo > 3). The nonvalidated questionnaire showed a high impact of quality of life. Follow-up was in median 30.5 months (0-162 months). OP is still a reliable procedure with good long-term results especially in infants < 1 year of age, which can be performed in a variety of centers.
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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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Robotically Assisted Surgery in Children—A Perspective. CHILDREN 2022; 9:children9060839. [PMID: 35740776 PMCID: PMC9221697 DOI: 10.3390/children9060839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 05/16/2022] [Accepted: 06/03/2022] [Indexed: 11/26/2022]
Abstract
The introduction of robotically assisted surgery was a milestone for minimally invasive surgery in the 21st century. Currently, there are two CE-approved robotically assisted surgery systems for use and development in pediatrics. Specifically, tremor filtration and optimal visualization are approaches which can have enormous benefits for procedures in small bodies. Robotically assisted surgery in children might have advantages compared to laparoscopic or open approaches. This review focuses on the research literature regarding robotically assisted surgery that has been published within the past decade. A literature search was conducted to identify studies comparing robotically assisted surgery with laparoscopic and open approaches. While reported applications in urology were the most cited, three other fields (gynecology, general surgery, and “others”) were also identified. In total, 36 of the publications reviewed suggested that robotically assisted surgery was a good alternative for pediatric procedures. After several years of experience of this surgery, a strong learning curve was evident in the literature. However, some authors have highlighted limitations, such as high cost and a limited spectrum of small-sized instruments. The recent introduction of reusable 3 mm instruments to the market might help to overcome these limitations. In the future, it can be anticipated that there will be a broader range of applications for robotically assisted surgery in selected pediatric surgeries, especially as surgical skills continue to improve and further system innovations emerge.
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Brownlee EM, Slack M. The Role of the Versius Surgical Robotic System in the Paediatric Population. CHILDREN 2022; 9:children9060805. [PMID: 35740742 PMCID: PMC9222178 DOI: 10.3390/children9060805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 12/05/2022]
Abstract
The uptake of robot-assisted surgery has continuously grown since its advent in the 1990s. While robot-assisted surgery is well-established in adult surgery, the rate of uptake in paediatric surgical centres has been slower. The advantages of a robot-assisted system, such as improved visibility, dexterity, and ergonomics, could make it a superior choice over the traditional laparoscopic approach. However, its implementation in the paediatric surgery arena has been limited primarily due to the unavailability of appropriately sized instruments as per paediatric body habitus, therefore, requiring more technologically advanced systems. The Versius surgical robotic system is a new modular platform that offers several benefits such as articulated instruments which pass through conventional 5 mm ports, compact arms for easier manoeuvrability and patient access, the ability to mimic conventional port placements, and adaptive machine learning concepts. Prior to its introduction to paediatric surgery, it needs to go through a careful pre-clinical and clinical research program.
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Affiliation(s)
- Ewan M. Brownlee
- Department of Paediatric Surgery and Urology, Southampton Children’s Hospital, University Hospital Southampton, Southampton SO16 6YD, UK;
| | - Mark Slack
- Clinical School, University of Cambridge, Cambridge CB2 2QQ, UK
- CMR Surgical Ltd., 1EBP, Milton Rd, Cambridge CB24 9NG, UK
- Correspondence: ; Tel.: +44-1223-755300 or +44-7766024389
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Ammer E, Mandt LS, Silbersdorff IC, Kahl F, Hagmayer Y. Robotic Anxiety—Parents’ Perception of Robot-Assisted Pediatric Surgery. CHILDREN 2022; 9:children9030399. [PMID: 35327771 PMCID: PMC8947283 DOI: 10.3390/children9030399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/03/2022] [Accepted: 03/05/2022] [Indexed: 11/23/2022]
Abstract
In contrast to many other countries, robot-assisted (RA) pediatric surgery is not yet very common in Germany. Although the first pediatric RA intervention was published in 2001, RA pediatric surgery is still perceived as a “new technology”. As a consequence, little is known about parents’ perception of this operation method. In this study, we analyzed parents‘ intention to let their child undergo RA and laparoscopic (LA) surgery. Two subsamples (online and at the University Medical Center Goettingen) received a questionnaire addressing attitude towards RA and LA pediatric surgery with the help of a case example. Results showed that parents had a higher intention to consent to LA surgery. Perceiving more benefits, assuming a positive attitude of the social environment, and feeling less anxiety increased intention. A mediation analysis indicated that the type of surgery affected intentions through assumed attitude of the social environment. Exploratory analyses showed that the perception of risks and anxiety reduced intention for only RA surgery. These findings should be considered in preoperational discussions with parents. Anxiety and perceived risks should especially be addressed in order to encounter hesitancy.
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Affiliation(s)
- Elisabeth Ammer
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Goettingen, 37075 Goettingen, Germany;
- Correspondence:
| | - Laura Sophie Mandt
- Georg-Elias-Mueller Institute for Psychology, University Goettingen, 37073 Goettingen, Germany; (L.S.M.); (I.C.S.); (Y.H.)
| | | | - Fritz Kahl
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Goettingen, 37075 Goettingen, Germany;
| | - York Hagmayer
- Georg-Elias-Mueller Institute for Psychology, University Goettingen, 37073 Goettingen, Germany; (L.S.M.); (I.C.S.); (Y.H.)
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Chandrasekharam VVS, Babu R. A systematic review and meta-analysis of conventional laparoscopic versus robot-assisted laparoscopic pyeloplasty in infants. J Pediatr Urol 2021; 17:502-510. [PMID: 33812779 DOI: 10.1016/j.jpurol.2021.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 03/11/2021] [Accepted: 03/11/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVE While there are several reports confirming the safety and efficacy of laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP) in children there have been none comparing LP and RALP specifically in infants. In this meta-analysis, we have compared the outcomes of LP and RALP in infants. METHODS Pubmed (Medline), Publon, Index Medicus and Embase were searched using the search terms: pyeloplasty (laparoscopic OR robot-assisted) AND (infant), to identify all papers pertaining to LP and RALP. Systematic review was performed to identify information regarding number of patients/renal units, age, body weight, operating time, hospital stay, success and complications. Meta-analysis of heterogeneity was reported with I2statistics. Once heterogeneity was found low, the pooled outcomes were compared with student's t test and Fishers exact test, wherever appropriate. RESULTS After screening a total of 267 articles, 18 articles were included (10 articles on LP, 7 on RALP, 1 reporting both), comprising 323 renal units for LP and 173 renal units for RALP. With low heterogeneity (I2: 0%) both groups were considered to have been conducted under similar conditions for fixed effect model. There was no significant difference between the success rates of LP or RALP (97.5% vs 94.8%; p = 0.21). The mean age at operation was significantly lower for LP (5.6 ± 1.8 months) than RALP (7.2 ± 1.2 months, P = 0.0001). The duration of surgery was 137 ± 45 min for LP while significantly higher at 179 ± 49 min for RALP (p = 0.0001). The mean (s.d) time to discharge was 2.0 (1.9) days for LP while 1.3 (0.4) days for RALP. The overall complication rate was significantly higher (summary table) for RALP than LP (p = 0.03), mainly due to more port-site hernias in RALP. DISCUSSION In the present study, we found that the success of LP and RALP in infants was similar. RALP in infants had longer duration of surgery, similar hospital stay and higher Clavien-3 complications than LP. While several studies have reported favorable outcomes for RALP over LP in children, this was not the case in infants. The smaller workspace, in an infant, can significantly limit the mobility of robotic instruments and increase the chance of port-site conflicts or trocar collisions. The use of larger robotic ports and instruments in the small space of infant abdomen might have been responsible for higher complications in RALP, including significantly larger number of port-site hernias. This meta-analysis represents the early experience of most RALP in infants, and it is possible that with experience RALP outcomes in infants also will catch up with LP. Miniaturization of robotic instruments might render RALP the future standard of care for pyeloplasty in infants.
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Affiliation(s)
- V V S Chandrasekharam
- Pediatric Surgery, Pediatric Urology and MAS, Ankura Hospitals for Women and Children, Hyderabad, Telangana, India.
| | - Ramesh Babu
- Pediatric Urology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
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