Robotic laparoscopic pyeloplasty

Early post-operative outcomes of robot-assisted pyeloplasty in patients with unilateral ureteropelvic junction obstruction

INTRODUCTION

Ureteropelvic junction obstruction (UPJO) is a commonly encountered abnormality and it can lead to serious consequences such as renal dysplasia eventually resulting in loss of kidney. Hence, early diagnosis and timely management remains the cornerstone of the treatment. The most anticipated technique amongst modern day urologist is the robot-assisted laparoscopic pyeloplasty (RALP). The study aims to determine early post-operative outcomes of robot-assisted laparoscopic transperitoneal pyeloplasty procedure in patients presenting with unilateral ureteropelvic junction obstruction to establish the local perspective.

METHODOLOGY

This is a descriptive study involving patients with ureteropelvic junction obstruction in a tertiary care facility in Karachi; Sindh Institute of Urology and Transplant (SIUT). A total of 46 participants were recruited. Robot-assisted laparoscopic transperitoneal dismembered Hynes-Anderson pyeloplasty was performed by a single surgeon with over 3 years of experience in the presence of the researcher. Early postoperative outcome total operative time, length of hospital stay, console time and blood loss were noted by the researcher as per operational definition. Data were analyzed on SPSS Version 22.

RESULTS

Mean age in our study was 46.51 years with the standard deviation of ± 10.87. Whereas, mean length of hospital stay, total operative time, total blood loss, console time, pre-hemoglobin, posthemoglobin, height, weight and BMI in our study was 1.19 ± 0.40 days, 64.58 ± 17.59 min, 9.56 ± 6.13 ml, 30.17 ± 4.99 min, 12.66 ± 1.47 ml, 11.79 ± 1.93 ml, 165.62 ± 8.23 cm, 68.34 ± 8.23 kg and 24.85 ± 3.34 kg/m2, respectively.

CONCLUSION

Recent advancements in technology have yielded the latest RALP technique which has been proven significantly better than existing approaches and similar results are reported by this study demonstrating improvement in peri-operative and post-operative outcomes ultimately ameliorating the quality of life of patients with UPJO.

Comparison of laparoscopic pyeloplasty vs. robot-assisted pyeloplasty for the management of ureteropelvic junction obstruction in children

BACKGROUND

Ureteropelvic junction obstruction (UPJO) is a commonly observed abnormality in pediatric urology. Minimally invasive approaches have gained popularity in recent years. Studies have demonstrated excellent results with both laparoscopic pyeloplasty (LAP) and robot-assisted pyeloplasty (RAP). Few studies have compared the experience of both procedures performed in a single institution. Our objective is to compare laparoscopic pyeloplasty and robot-assisted pyeloplasty in the Puerto Rican pediatric population.

METHODS

We conducted a retrospective cohort study using our clinic's database on patients with UPJO that were operated by the same surgeon (MPB) from 2008 to 2019. Statistical analysis was conducted of demographics, preoperative studies, perioperative data and complications of both procedures. This study was approved by our local IRB committee.

RESULTS

A total of 86 patients that underwent pyeloplasty with at least 3 years of follow up were recorded for this study. Laparoscopic pyeloplasty and robot-assisted pyeloplasty were performed in 44 (51.1%) and 42 (48.8%) patients, respectively. Patient age ranged between 4 months and 17 years (LAP group - mean age of 6.19 years/RAP group - mean age of 7.07 years). Success rates was high in this series (LAP - 100% and RAP -95%). Using Wilcoxon signed rank test and Mann whitney sum test, significant differences between preoperative and postoperative hydronephrosis grading were observed in both LAP and RAP groups. However, no significant difference was seen regarding reduction of hydronephrosis grading when comparing both groups. No intraoperative complications were seen on either group.

CONCLUSION

Both LAP and RAP are safe and effective procedures that can properly manage UPJO. Our study shows that, under experienced hands, pure laparoscopic pyeloplasty achieves comparable results to robotic assisted laparoscopic pyeloplasty. Pediatric urologists should be comfortable offering either of these approaches as they demonstrate high success rates in our pediatric population. Selection of LAP vs. RAP approach depends on the Surgeon's preference or experience, and on institutional availability. Minimally invasive therapies will continue to gain popularity with future advances in laparoscopic and robotic technology.

Is secondary robotic pyeloplasty safe and effective as primary robotic pyeloplasty? A systematic review and meta-analysis

Robot-assisted laparoscopic pyeloplasty (RLP) has excellent surgical safety and efficacy in primary pyeloplasty. In recent, the application of robotics has explored to more complex surgical conditions such as failed pyeloplasty. This meta-analysis aimed to evaluate the surgical and clinical outcomes of secondary RLP compared with primary RLP. Following PRISMA guidelines, we carried out an extensive literature search in the PubMed, Web of Science, Cochrane Library, Scopus, and Google Scholar to extract the published articles comparing primary vs. secondary RLP up to April 2019. Interested surgical and clinical outcomes were extracted from each study and then used RevMan 5.3 Software for meta-analysis comparison. Furthermore, the quality of each study was assessed using the Modified Newcastle-Ottawa Scale for cohort studies. Our search has yielded seven studies that met our inclusion criteria. These studies contained 613 vs. 107 patients in primary vs. secondary RLP, respectively. Using random effect model, the analysis showed no statistical difference between the groups in the presence of a crossing vessel, complications, length of hospital stays (LOS), and follow-up period. However, the operative time, estimated blood loss (EBL), and recurrence rate were significantly higher in the secondary RLP compared with primary RLP (p = 0.004), (p = 0.01), and (p = 0.04), respectively. Our results indicate that secondary RLP is associated with significantly increased operative time and EBL and higher recurrence rates compared with primary RLP. We believe that our findings might help surgeon's decision making in patient selection and consultation during redo pyeloplasty surgical planning.

Learning robotic pyeloplasty without simulators: an assessment of the learning curve in the early robotic era

OBJECTIVE

To analyze our experience and learning curve for robotic pyeloplasty during this robotic procedure.

METHODS

Ninety-nine patients underwent 100 consecutive procedures. Cases were divided into 4 groups of 25 consecutive procedures to analyze the learning curve.

RESULTS

The median anastomosis times were 50.0, 36.8, 34.2 and 29.0 minutes (p=0.137) in the sequential groups, respectively. The median operative times were 144.6, 119.2, 114.5 and 94.6 minutes, with a significant difference between groups 1 and 2 (p=0.015), 1 and 3 (p=0.002), 1 and 4 (p<0.001) and 2 and 4 (p=0.022). The mean hospital stay was 7.08, 4.76, 4.88 and 4.20 days, with a difference between groups 1 and 2 (p<0.001), 1 and 3 (p<0.001) and 1 and 4 (p<0.001). Clinical and radiological improvements were observed in 98.9% of patients. One patient presented with recurrent obstruction.

CONCLUSIONS

Our results demonstrate a high success rate with low complication rates. A significant decrease in hospital stay and surgical time was evident after 25 cases.

Reduction corporoplasty

OBJECTIVE

Here we present the first video demonstration of reduction corporoplasty in the management of phallic disfigurement in a 17 year old man with a history sickle cell disease and priapism.

INTRODUCTION

Surgical management of aneurysmal dilation of the corpora has yet to be defined in the literature.

MATERIALS AND METHODS

We preformed bilateral elliptical incisions over the lateral corpora as management of aneurysmal dilation of the corpora to correct phallic disfigurement.

RESULTS

The patient tolerated the procedure well and has resolution of his corporal disfigurement.

CONCLUSIONS

Reduction corporoplasty using bilateral lateral elliptical incisions in the management of aneurysmal dilation of the corpora is a safe an feasible operation in the management of phallic disfigurement.

Robotic transmesocolonic Pyelolithotomy of horseshoe kidney

Introduction

The purpose of this video is to demonstrate the use of the robot to perform a transmesocolonic pyelolithotomy of a horseshoe kidney.

Materials and Methods

A 35-year old female presented with vague abdominal pain. CT scan imaging revealed the presence of a left horseshoe kidney with multiple pelvicalyceal stones. The patient was positioned in the supine position. A total of 4 ports were introduced. A 3-arm da Vinci robotic surgical system was docked, and the arms were connected. First, the dilated renal pelvis was identified behind the thin mesocolon. The mesocolon was entered and renal pelvis was dissected completely from the surrounding fat. Then, the renal pelvis was opened after adequate dissection and stones were visualized inside the calyces. By Prograsp forceps, stones were removed from all the calyces under vision and were extracted from the assistant trocar. Finally, the pylotomy incision was closed using 4 0 Maxon in a continuous fashion and the mesocolon was closed using 3 0 PDS interrupted sutures. A JP drain was placed.

Result

Operative time was forty-five minutes, blood loss was 100 ml. The patient was discharged after 48 hours with no immediate complications.

Conclusion

The utilization of minimal invasive surgery using the robot to extract multiple pelvicalyceal stones from a horseshoe kidney without reflecting the mesocolon proved to be a feasible and novel way in the management of complex stone disease improving the outcome with minimal morbidity.