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Journal of Pediatric Urology (2014) xx, 1e6
Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery Danesh Bansal, Nicholas G. Cost, Christopher M. Bean, Brian A. Vanderbrink, Marion Schulte, Paul H. Noh* Division of Pediatric Urology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, ML 5037, Cincinnati, OH 45229, USA Received 14 July 2013; accepted 24 January 2014
KEYWORDS Robotics; Pyeloplasty; Ureteroureterostomy; Pediatrics; Infant
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 3e12 months). Median weight was 7.7 kg (range 5.8e10.9 kg). Median operative time was 128 min (range 95e205 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 1e2). Median follow-up was 10 months (range 3e18 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. ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Robot-assisted laparoscopic (RAL) surgery offers the potential to perform complex reconstructive surgical procedures
to a wider population. For urological procedures, including pyeloplasty and ureteroureterostomy (UU), RAL has been successfully performed and may provide an advantage over open surgery with minimal morbidity in the pediatric
* Corresponding author. Tel.: þ1 513 636 4975; fax: þ1 513 636 6753. E-mail addresses: [email protected], [email protected] (P.H. Noh). http://dx.doi.org/10.1016/j.jpurol.2014.01.029 1477-5131/ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Bansal D, et al., Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2014.01.029
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2 population [1e4]. However, robotic surgery is not commonly performed in infants. Laparoscopic suturing is technically demanding with the potential for a long learning curve, which may limit its widespread application for reconstructive surgery in pediatric urology [5,6]. Robotic surgery helps mitigate the challenges of laparoscopic suturing. Conventional laparoscopic surgery in infants is well established [7e9]. However, there is a paucity of reports evaluating robotic techniques in this population. The role of robotic surgery has yet to be defined in infants, in large part due to concerns regarding the more limited working space. Many question whether the benefits of robotics can be realized in the youngest and smallest patients. To our knowledge, only one study of robot-assisted urologic surgery exclusively in infants has been reported [10]. Herein, we present the largest series of infant RAL upper urinary tract reconstructive surgery and the first to include UU.
Materials and methods Study population The medical records of all children under 1 year of age at surgery who underwent RAL upper urinary tract reconstruction at a single pediatric institution from March 2009 to February 2013 were retrospectively reviewed. Chart review was performed after Institutional Review Board approval. All patients had preoperative renal ultrasound and diuretic renogram evaluations. Procedures included Anderson-Hynes dismembered pyeloplasty and ipsilateral UU. After discussion of all treatment options, families specifically consented to robotic procedures. All cases were performed with a transperitoneal approach. Operative indications included ureteropelvic junction obstruction, congenital mid-ureteral obstruction, and an obstructed ectopic ureter in a duplication anomaly. All procedures were performed using the daVinci S Surgical System. Data included age, weight, operative time, blood loss, stents, drains, length of hospital stay, postoperative analgesics, complications, and length of follow-up period. Cystoscopy was performed preoperatively to assess anatomy and place ureteral catheters. The fascia of all trocar sites was closed with absorbable suture. All patients had an indwelling urethral catheter, which was typically removed the following morning. Ureteral stents were placed during the anastomosis, when technically feasible. Operative time was recorded as time from skin incision for port placement to closure of skin incisions. Operative time did not include cystoscopy before skin incision.
Study objective This retrospective, descriptive study was designed with the objective of assessing outcomes, including the feasibility, safety, and efficacy, of RAL surgery for upper urinary tract reconstruction in infants.
Surgical technique Patients were placed in the flank position. All procedures were performed with an 8.5-mm camera trocar and two
D. Bansal et al. 8-mm trocars based on surgeon preference. The larger 8mm instruments were preferred to get the maximum benefit of the endowrist technology in a small working space. The 5-mm instruments require a larger working space. Trocars were placed under direct vision. Conventional trocar placement and hidden incision endoscopic surgery (HIdES) techniques were utilized [11]. The colon was mobilized in all cases due to surgeon preference. Assistant ports were not utilized.
Andersonehynes dismembered pyeloplasty The retroperitoneum was exposed by reflecting the ipsilateral colon. A transmesenteric approach was not used because of surgeon preference. The renal pelvis, ureteropelvic junction, and ureter were mobilized. Gonadal vessels were preserved. A percutaneous Prolene suture was placed into the renal pelvis to provide traction and exposure. An incision was made into the renal pelvis above the ureteropelvic junction. The obstructed segment was used as a handle for manipulation and eventually excised. The ureter was spatulated to achieve a widely patent anastomosis. The anastomoses were performed with a modified double-armed running 5-0 or 6-0 polydioxanone (PDS). Tying two sutures together created the double-armed suture, leaving a suture length of 4e8 cm from the knot to each needle. The sutures were brought in holding the tails with a standard laparoscopic instrument through a working trocar. An indwelling ureteral stent was placed antegrade, percutaneously through an angiocatheter, during the anastomosis when technically feasible.
Ipsilateral duplex system UU After access and trocar placement were achieved, the retroperitoneum was exposed, including reflecting the colon. The recipient left lower pole ureter and the obstructed dilated upper pole ureter were identified. The lower pole ureter was left in situ, with minimal dissection to preserve blood supply. Using robotic Potts scissors, a longitudinal ureterotomy was made in the mid-ureter of the lower pole system in order to match the diameter of the obstructed upper pole ureter. The upper pole ureter was divided transversely. The upper to lower UU anastomosis was performed using running 6-0 PDS with a double-armed needle. Redundant mid-ureter was excised but distal ureters were left undisturbed. The distal stump of the obstructed ureter was left open. A retrograde ureteral stent was placed at the time of cystoscopy into the recipient ureter.
Ipsilateral single system UU After access and trocar placement were achieved, the retroperitoneum was exposed, including reflecting the colon. The congenital mid-ureteral obstruction and dilated proximal ureter were identified. The ureter was transected proximal and distal to the obstruction. The distal ureter was spatulated to achieve a widely patent anastomosis. The anastomosis was performed using running 6-0 PDS with a double-armed needle. An indwelling ureteral stent was
Please cite this article in press as: Bansal D, et al., Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2014.01.029
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Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery placed antegrade, percutaneously through an angiocatheter, during the anastomosis. The distal curl was placed in the bladder, and the proximal curl of the stent was manipulated proximally higher into the upper urinary tract.
Perioperative analgesia Patients received local anesthesia at trocar sites and regional blocks on a case-by-case basis. Routine postoperative inpatient analgesia included scheduled intravenous or oral acetaminophen. Narcotics and ketorolac were administered in a non-uniform regimen. Narcotic use was converted to morphine sulfate equivalents. Diet was advanced as tolerated. Ureteral stents were typically removed 4e6 weeks postoperatively. Routine postoperative imaging included renal ultrasounds. Success was defined as improved hydronephrosis on a postoperative renal ultrasound. Complications were assessed according to the Clavien classification system [12].
Results A total of 10 infants (4 male, 6 female) met the inclusion criteria. A single surgeon with extensive experience in minimally invasive surgery (MIS), including robotics and laparoscopy, performed all procedures. Laterality was five right- and five left-sided procedures. Initial presentation consisted of prenatal hydronephrosis in nine (90%) patients and urinary tract infection in one (10%) patient. Eight pyeloplasties (4 right, 4 left), one UU for mid-ureteral obstruction (Figs. 1 and 2), and one upper to lower UU for an obstructed ectopic upper pole ureter were performed. Seven (70%) pyeloplasties and one (10%) single system UU were performed using the HIdES technique [11].
3
Median age at surgery was 8 months (range 3e12 months). Median weight was 7.7 kg (range 5.8e10.9 kg). All patients had intrinsic obstruction. Three patients were symptomatic. One 4-month-old patient underwent a left upper to lower UU, after temporizing treatment with a nephrostomy tube due to infection in the setting of an obstructed upper pole ectopic ureter with a functional renal moiety. Two other infants were felt to be symptomatic with colic, relieved after surgery, and vomiting, which was reproduced during diuretic renography. Median operative time was 128 min (range 95e205 min). Median operative time for pyeloplasty was 130 min (range 95e205 min). Operative time for the single system UU was 115 min, and for the duplex system UU was 140 min. There was no significant blood loss, intraoperative complication, or conversion to open or standard laparoscopy for any procedure. Antegrade indwelling ureteral stent placement was achieved in six cases. When a ureteral stent placement was not feasible due to a tight ureteral orifice, one patient had an unstented repair with an external JacksonePratt drain, one patient had an externalized ureteral catheter placed retrograde at the end of the procedure, and one patient had an externalized nephroureteral catheter positioned robotically during the repair. The catheter was brought into the abdomen through a working trocar. It was passed inside the renal pelvis, out through the interpolar renal parenchyma laterally, and finally through the flank for externalization. The ureteral end of the catheter was passed antegrade down the ureter, and the anastomosis was completed. The patient undergoing a left upper to lower UU had a retrograde indwelling ureteral stent placed in the lower pole ureter at the time of cystoscopy. This patient had a pre-existing left upper pole nephrostomy tube placed for previous infection.
Figure 1 (A) Preoperative renal ultrasound. (B) Intraoperative retrograde ureteropyelogram demonstrating mid ureteral obstruction. (C) Intraoperative view of mid-ureteral obstruction. (D) Postoperative renal ultrasound 6 months after surgery.
Please cite this article in press as: Bansal D, et al., Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2014.01.029
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D. Bansal et al.
Figure 2 Postoperative appearance of hidden incision endoscopic surgery incisions: (A) 1 month after surgery; (B) 4 months after surgery; (C) 6 months after surgery.
Median hospital stay was 1 day (range 1e2 days). One (10%) patient received a regional block. Eight (80%) patients did not receive postoperative narcotics. One patient (5 months of age) received 0.05 mg/kg morphine equivalent per day of hospital stay and another patient (10 months of age) received 0.03 mg/kg morphine equivalent per day of hospital stay. Seven (70%) patients, median age 11.5 months (range 5.5e14.9 months) were administered scheduled postoperative Ketorolac. All patients received scheduled intravenous or oral postoperative Acetaminophen. Median follow-up was 10 months (range 3e18 months). Initial postoperative renal ultrasound was performed at 1e3 months. Renal ultrasound showed improved hydronephrosis in all patients. Three (30%) complications occurred. There were no complications in the two patients that underwent UU. There were two grade I and one grade IIIb complications. The patient with an unstented pyeloplasty presented with a urine leak on postoperative day 4, which was initially managed with a percutaneous nephrostomy tube. An externalized ureteral catheter was placed because of unsuccessful stent placement. Indwelling ureteral stent placement and nephrostomy tube removal were achieved 2 weeks later. One patient was readmitted for ileus on postoperative day 2, managed expectantly, and discharged on postoperative day 4. One patient had a urinary tract infection with an indwelling ureteral stent that was treated with oral antibiotics.
Discussion MIS has become increasingly popular in the management of many pediatric urological conditions, as seen by the increasing number of reports in the literature. However, the evolution of laparoscopic surgical techniques from
extirpative to reconstructive surgery in pediatric urology has been slowed due to the challenge of laparoscopic suturing [5,6]. Robotic technology has allowed surgeons to overcome the limitations of conventional laparoscopy. Wristed instrumentation utilized during robotic surgery has the potential to shorten the learning curve for reconstructive surgery. It opens the door for more surgeons to perform MIS with precise suturing and delicate tissue handling, a skill that may not be achievable for every surgeon due to the limited number of reconstructive procedures any one surgeon may be performing on a consistent basis. Robotic technology has been successfully used in many different pediatric urological procedures. However, there has only been one study of robotic pyeloplasty exclusively in the infant population [10]. Concerns include small patient size for robotic instrumentation, larger trocars, robotic malfunction, costs, and limited benefits over open surgery. To the best of our knowledge, we report the largest series of infant RAL upper urinary tract reconstructive surgery and the first to include UU in infants. Our results are comparable with published data on infant laparoscopic or robotic upper urinary tract reconstructive surgery (Table 1) [9,10,13e18] and infant open pyeloplasty [19e22]. While not explicitly evaluated in our analysis, families verbally expressed satisfaction with the postoperative appearance of the surgical incisions, particularly for patients who had the HIdES technique trocar placement. However, reports assessing patient and family satisfaction with surgical scars between various types of surgical approaches are lacking and further studies are warranted. The operative time in our series was shorter than some and similar to other reports [9,10,13e18]. It is noteworthy that our operative time was similar to that reported in the previous report of infant robotic pyeloplasty [10].
Please cite this article in press as: Bansal D, et al., Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2014.01.029
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Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery Table 1
5
Previous reports of infant laparoscopic or robotic reconstructive surgery.
No. infants/total no. patients Median/mean age months (range) Median/mean operative time minutes No. open conversions Median/mean length of stay (days) No. complications (%) No. infant success/total no. infants (%) No. secondary procedures Morphine equivalent usage (mg/kg) Ketorolac usage (mg/kg) No. regional blocks
Turner et al.
Piaggio et al. Kutikov et al.
Neheman Fuchs et al. et al.
Tong et al. Gonzalez et al.
29/29
11/37
8/8
21/21
26/26
23/23
6 (2e11)
61 (0.5e216)
4.5 (3e5) 4 (4e15)
7.3 (2e11)
245
278
108
237
4.4 (not reported) 134
Not 9/9 reported/8 51 (1e190) 5.6 (3e8)
103
211
123
0 1.3
0 2.4
0 1.2
0 2
1 0 Not reported 3
0 3
0 1.4
3 (10.3%) 22/24 (92%) 2 Not reported Not reported Not reported
5 (13.5%) 10/11 (91%)
0 8/8 (100%) 0 Not reported Not reported Not reported
2 (9.5%) 16/17 (94%) 1 0.17
1 (3.8%) 3 (13%) 26/26 (100%) 22/23 (96%) 1 2 Not reported Not reported Not reported Not reported Not reported Not reported
2 (25%) 8/8 (100%)
0 9/9 (100%) 0 Not reported Not reported Not reported
0 0.28 0.36 0
Additionally, operative time in our study was comparable to some but longer than other reports of open pyeloplasty [19e22]. However, the definition for operative time was not clearly reported in all of the previous studies. Our shorter operative than some reports with conventional laparoscopy may be a reflection of benefits provided by robotics. In our series, there no were intraoperative complications or conversions to open or pure laparoscopic surgery. There were three postoperative complications, all of which coincidentally occurred in patients undergoing pyeloplasty. None of the experienced complications were directly related to robotics. An important point in analyzing the benefits of MIS, including robotic surgery in the infant population, is the length of hospitalization and use of postoperative analgesics. The length of stay in our series is similar to previous studies of infant laparoscopic and robotic urological surgery. Postoperative Ketorolac use was comparable to other reports [14,16,17]. Postoperative narcotics and use of regional blocks were lower in our study as compared to these studies. The lack of narcotic use in our series is not easily explained, since larger trocars were used for our robotic procedures than the trocars used with conventional laparoscopy. One potential explanation may be our shorter operative time, which may have decreased postoperative pain due to a shorter duration of abdominal distention. The infants may have also benefitted from utilization of intravenous acetaminophen. Regardless, the difference in overall narcotic use is compelling in validating the use of robotics to perform reconstructive procedures in infants. There are several limitations to this study, including a retrospective design, small patient sample size, single surgeon experience, and lack of a comparison group for outcomes and cost analysis. Despite these limitations, we believe this report substantiates the experience of Kutikov et al. [10]. Our study shows the effectiveness of
Not reported 4
0 0.1 0.5 Not reported
Kutikov et al.
reconstructive upper urinary tract surgery in infants and the potential advantage for treating mid-ureteral obstruction, which may be challenging to address through an open incision if placed in a sub-optimal location. RAL upper urinary tract surgery has the potential to provide a better clinical outcome than open surgery, even in the infant population. All of our patients were at least 5 kg in weight. Weight, as one surrogate for intra-abdominal working space, more than age may be the critical factor in applying robotics to the infant population. Since our study did not include any patients less than 5 kg in weight, the questions remain unanswered for the smallest of infants. Although our study demonstrated beneficial outcomes, future studies are required to validate our findings. Cost has been one of the criticisms of robotic surgery. However, one recent study has reported similar institutional costs for pure laparoscopic and robotic pyeloplasty when accounting for multiple surgeons and ureteral stenting techniques [23]. Another study has reported significantly lower direct costs for RAL urologic surgery than open urologic surgery [24]. The cost difference was primarily due to the difference in duration of hospital stay between patients undergoing open and RAL surgery. And finally, RAL pyeloplasty has also been associated with human capital gains of decreased lost parental wages and lower hospitalization expenses over open pyeloplasty in children [25].
Conclusion Infant RAL upper urinary tract reconstructive surgery is technically feasible, safe, and effective. It can be applied for duplication anomalies and single system obstructions in infants. Further studies are warranted to better define its role compared with open surgery or other alternatives for MIS.
Please cite this article in press as: Bansal D, et al., Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2014.01.029
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Conflict of interest None.
Funding None.
Ethical approval Approval was not required.
References [1] Smith KM, Shrivastava D, Ravish IR, Nerli RB, Shukla AR. Robotassisted laparoscopic ureteroureterostomy for proximal ureteral obstructions in children. J Pediatr Urol 2009;5:475e9. [2] Leavitt DA, Rambachan A, Haberman K, Demarco R, Shukla AR. Robot-assisted laparoscopic ipsilateral ureteroureterostomy for ectopic ureters in children: description of technique. J Endourol 2012;26:1279e83. [3] Orvieto MA, Large M, Gundeti MS. Robotic paediatric urology. BJU Int 2012;110:2e13. [4] Trevisani LF, Nguyen HT. Current controversies in pediatric urologic robotic surgery. Curr Opin Urol 2013;23:72e7. [5] Casale P, Grady RW, Joyner BD, Zeltser IS, Figueroa TE, Mitchell ME. Comparison of dismembered and nondismembered laparoscopic pyeloplasty in the pediatric patient. J Endourol 2004;18:875e8. [6] Casale P, Kojima Y. Robotic-assisted laparoscopic surgery in pediatric urology: an update. Scand J Surg 2009;98:110e9. [7] Storm DW, Modi A, Jayanthi VR. Laparoscopic ipsilateral ureteroureterostomy in the management of ureteral ectopia in infants and children. J Pediatr Urol 2011;7:529e33. [8] Mulholland TL, Kropp BP, Wong C. Laparoscopic renal surgery in infants 10 kg or less. J Endourol 2005;19:397e400. [9] Turner 2nd RM, Fox JA, Tomaszewski JJ, Schneck FX, Docimo SG, Ost MC. Laparoscopic pyeloplasty for ureteropelvic junction obstruction in infants. J Urol 2013;189: 1503e7. [10] Kutikov A, Nguyen M, Guzzo T, Canter D, Casale P. Robot assisted pyeloplasty in the infant-lessons learned. J Urol 2006; 176:2237e9. discussion 9e40. [11] Gargollo PC. Hidden incision endoscopic surgery: description of technique, parental satisfaction and applications. J Urol 2011;185:1425e31. [12] Dindo D, Demartines N, Clavien P-A. Classification of surgical complications. Ann Surg 2004;240:205e13.
D. Bansal et al. [13] Fuchs J, Luithle T, Warmann SW, Haber P, Blumenstock G, Szavay P. Laparoscopic surgery on upper urinary tract in children younger than 1 year: technical aspects and functional outcome. J Urol 2009;182:1561e8. [14] Gonzalez R, Piaggio L. Initial experience with laparoscopic ipsilateral ureteroureterostomy in infants and children for duplication anomalies of the urinary tract. J Urol 2007;177: 2315e8. [15] Kutikov A, Resnick M, Casale P. Laparoscopic pyeloplasty in the infant younger than 6 monthsdis it technically possible? J Urol 2006;175:1477e9. [16] Neheman A, Noh PH, Piaggio L, Gonzalez R. The role of laparoscopic surgery for urinary tract reconstruction in infants weighing less than 10 kg: a comparison with open surgery. J Pediatr Urol 2008;4:192e6. [17] Piaggio LA, Franc-Guimond J, Noh PH, Wehry M, Figueroa TE, Barthold J, et al. Transperitoneal laparoscopic pyeloplasty for primary repair of ureteropelvic junction obstruction in infants and children: comparison with open surgery. J Urol 2007;178: 1579e83. [18] Tong Q, Zheng L, Tang S, Zeng F, Du Z, Mei H, et al. Comparison of laparoscopic-assisted versus open dismembered pyeloplasty for ureteropelvic junction obstruction in infants: intermediate results. Urology 2009;74:889e93. [19] Chacko JK, Koyle MA, Mingin GC, Furness 3rd PD. The minimally invasive open pyeloplasty. J Pediatr Urol 2006;2: 368e72. [20] Chacko JK, Koyle MA, Mingin GC, Furness 3rd PD. Minimally invasive open renal surgery. J Urol 2007;178:1575e7. discussion 7e8. [21] Kajbafzadeh AM, Tourchi A, Nezami BG, Khakpour M, Mousavian AA, Talab SS. Miniature pyeloplasty as a minimally invasive surgery with less than 1 day admission in infants. J Pediatr Urol 2011;7:283e8. [22] Ruiz E, Soria R, Ormaechea E, Lino MM, Moldes JM, de Badiola FI. Simplified open approach to surgical treatment of ureteropelvic junction obstruction in young children and infants. J Urol 2011;185:2512e6. [23] Casella DP, Fox JA, Schneck FX, Cannon GM, Ost MC. Cost analysis of pediatric robot-assisted and laparoscopic pyeloplasty. J Urol 2013;189:1083e6. [24] Rowe CK, Pierce MW, Tecci KC, Houck CS, Mandell J, Retik AB, et al. A comparative direct cost analysis of pediatric urologic robot-assisted laparoscopic surgery versus open surgery: could robot-assisted surgery be less expensive? J Endourol 2012;26: 871e7. [25] Behan JW, Kim SS, Dorey F, De Filippo RE, Chang AY, Hardy BE, et al. Human capital gains associated with robotic assisted laparoscopic pyeloplasty in children compared to open pyeloplasty. J Urol 2011;186:1663e7.
Please cite this article in press as: Bansal D, et al., Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2014.01.029
MODEL
Journal of Pediatric Urology (2014) xx, 1e6
Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery Danesh Bansal, Nicholas G. Cost, Christopher M. Bean, Brian A. Vanderbrink, Marion Schulte, Paul H. Noh* Division of Pediatric Urology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, ML 5037, Cincinnati, OH 45229, USA Received 14 July 2013; accepted 24 January 2014
KEYWORDS Robotics; Pyeloplasty; Ureteroureterostomy; Pediatrics; Infant
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 3e12 months). Median weight was 7.7 kg (range 5.8e10.9 kg). Median operative time was 128 min (range 95e205 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 1e2). Median follow-up was 10 months (range 3e18 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. ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Robot-assisted laparoscopic (RAL) surgery offers the potential to perform complex reconstructive surgical procedures
to a wider population. For urological procedures, including pyeloplasty and ureteroureterostomy (UU), RAL has been successfully performed and may provide an advantage over open surgery with minimal morbidity in the pediatric
* Corresponding author. Tel.: þ1 513 636 4975; fax: þ1 513 636 6753. E-mail addresses: [email protected], [email protected] (P.H. Noh). http://dx.doi.org/10.1016/j.jpurol.2014.01.029 1477-5131/ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Bansal D, et al., Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2014.01.029
+
MODEL
2 population [1e4]. However, robotic surgery is not commonly performed in infants. Laparoscopic suturing is technically demanding with the potential for a long learning curve, which may limit its widespread application for reconstructive surgery in pediatric urology [5,6]. Robotic surgery helps mitigate the challenges of laparoscopic suturing. Conventional laparoscopic surgery in infants is well established [7e9]. However, there is a paucity of reports evaluating robotic techniques in this population. The role of robotic surgery has yet to be defined in infants, in large part due to concerns regarding the more limited working space. Many question whether the benefits of robotics can be realized in the youngest and smallest patients. To our knowledge, only one study of robot-assisted urologic surgery exclusively in infants has been reported [10]. Herein, we present the largest series of infant RAL upper urinary tract reconstructive surgery and the first to include UU.
Materials and methods Study population The medical records of all children under 1 year of age at surgery who underwent RAL upper urinary tract reconstruction at a single pediatric institution from March 2009 to February 2013 were retrospectively reviewed. Chart review was performed after Institutional Review Board approval. All patients had preoperative renal ultrasound and diuretic renogram evaluations. Procedures included Anderson-Hynes dismembered pyeloplasty and ipsilateral UU. After discussion of all treatment options, families specifically consented to robotic procedures. All cases were performed with a transperitoneal approach. Operative indications included ureteropelvic junction obstruction, congenital mid-ureteral obstruction, and an obstructed ectopic ureter in a duplication anomaly. All procedures were performed using the daVinci S Surgical System. Data included age, weight, operative time, blood loss, stents, drains, length of hospital stay, postoperative analgesics, complications, and length of follow-up period. Cystoscopy was performed preoperatively to assess anatomy and place ureteral catheters. The fascia of all trocar sites was closed with absorbable suture. All patients had an indwelling urethral catheter, which was typically removed the following morning. Ureteral stents were placed during the anastomosis, when technically feasible. Operative time was recorded as time from skin incision for port placement to closure of skin incisions. Operative time did not include cystoscopy before skin incision.
Study objective This retrospective, descriptive study was designed with the objective of assessing outcomes, including the feasibility, safety, and efficacy, of RAL surgery for upper urinary tract reconstruction in infants.
Surgical technique Patients were placed in the flank position. All procedures were performed with an 8.5-mm camera trocar and two
D. Bansal et al. 8-mm trocars based on surgeon preference. The larger 8mm instruments were preferred to get the maximum benefit of the endowrist technology in a small working space. The 5-mm instruments require a larger working space. Trocars were placed under direct vision. Conventional trocar placement and hidden incision endoscopic surgery (HIdES) techniques were utilized [11]. The colon was mobilized in all cases due to surgeon preference. Assistant ports were not utilized.
Andersonehynes dismembered pyeloplasty The retroperitoneum was exposed by reflecting the ipsilateral colon. A transmesenteric approach was not used because of surgeon preference. The renal pelvis, ureteropelvic junction, and ureter were mobilized. Gonadal vessels were preserved. A percutaneous Prolene suture was placed into the renal pelvis to provide traction and exposure. An incision was made into the renal pelvis above the ureteropelvic junction. The obstructed segment was used as a handle for manipulation and eventually excised. The ureter was spatulated to achieve a widely patent anastomosis. The anastomoses were performed with a modified double-armed running 5-0 or 6-0 polydioxanone (PDS). Tying two sutures together created the double-armed suture, leaving a suture length of 4e8 cm from the knot to each needle. The sutures were brought in holding the tails with a standard laparoscopic instrument through a working trocar. An indwelling ureteral stent was placed antegrade, percutaneously through an angiocatheter, during the anastomosis when technically feasible.
Ipsilateral duplex system UU After access and trocar placement were achieved, the retroperitoneum was exposed, including reflecting the colon. The recipient left lower pole ureter and the obstructed dilated upper pole ureter were identified. The lower pole ureter was left in situ, with minimal dissection to preserve blood supply. Using robotic Potts scissors, a longitudinal ureterotomy was made in the mid-ureter of the lower pole system in order to match the diameter of the obstructed upper pole ureter. The upper pole ureter was divided transversely. The upper to lower UU anastomosis was performed using running 6-0 PDS with a double-armed needle. Redundant mid-ureter was excised but distal ureters were left undisturbed. The distal stump of the obstructed ureter was left open. A retrograde ureteral stent was placed at the time of cystoscopy into the recipient ureter.
Ipsilateral single system UU After access and trocar placement were achieved, the retroperitoneum was exposed, including reflecting the colon. The congenital mid-ureteral obstruction and dilated proximal ureter were identified. The ureter was transected proximal and distal to the obstruction. The distal ureter was spatulated to achieve a widely patent anastomosis. The anastomosis was performed using running 6-0 PDS with a double-armed needle. An indwelling ureteral stent was
Please cite this article in press as: Bansal D, et al., Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2014.01.029
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Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery placed antegrade, percutaneously through an angiocatheter, during the anastomosis. The distal curl was placed in the bladder, and the proximal curl of the stent was manipulated proximally higher into the upper urinary tract.
Perioperative analgesia Patients received local anesthesia at trocar sites and regional blocks on a case-by-case basis. Routine postoperative inpatient analgesia included scheduled intravenous or oral acetaminophen. Narcotics and ketorolac were administered in a non-uniform regimen. Narcotic use was converted to morphine sulfate equivalents. Diet was advanced as tolerated. Ureteral stents were typically removed 4e6 weeks postoperatively. Routine postoperative imaging included renal ultrasounds. Success was defined as improved hydronephrosis on a postoperative renal ultrasound. Complications were assessed according to the Clavien classification system [12].
Results A total of 10 infants (4 male, 6 female) met the inclusion criteria. A single surgeon with extensive experience in minimally invasive surgery (MIS), including robotics and laparoscopy, performed all procedures. Laterality was five right- and five left-sided procedures. Initial presentation consisted of prenatal hydronephrosis in nine (90%) patients and urinary tract infection in one (10%) patient. Eight pyeloplasties (4 right, 4 left), one UU for mid-ureteral obstruction (Figs. 1 and 2), and one upper to lower UU for an obstructed ectopic upper pole ureter were performed. Seven (70%) pyeloplasties and one (10%) single system UU were performed using the HIdES technique [11].
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Median age at surgery was 8 months (range 3e12 months). Median weight was 7.7 kg (range 5.8e10.9 kg). All patients had intrinsic obstruction. Three patients were symptomatic. One 4-month-old patient underwent a left upper to lower UU, after temporizing treatment with a nephrostomy tube due to infection in the setting of an obstructed upper pole ectopic ureter with a functional renal moiety. Two other infants were felt to be symptomatic with colic, relieved after surgery, and vomiting, which was reproduced during diuretic renography. Median operative time was 128 min (range 95e205 min). Median operative time for pyeloplasty was 130 min (range 95e205 min). Operative time for the single system UU was 115 min, and for the duplex system UU was 140 min. There was no significant blood loss, intraoperative complication, or conversion to open or standard laparoscopy for any procedure. Antegrade indwelling ureteral stent placement was achieved in six cases. When a ureteral stent placement was not feasible due to a tight ureteral orifice, one patient had an unstented repair with an external JacksonePratt drain, one patient had an externalized ureteral catheter placed retrograde at the end of the procedure, and one patient had an externalized nephroureteral catheter positioned robotically during the repair. The catheter was brought into the abdomen through a working trocar. It was passed inside the renal pelvis, out through the interpolar renal parenchyma laterally, and finally through the flank for externalization. The ureteral end of the catheter was passed antegrade down the ureter, and the anastomosis was completed. The patient undergoing a left upper to lower UU had a retrograde indwelling ureteral stent placed in the lower pole ureter at the time of cystoscopy. This patient had a pre-existing left upper pole nephrostomy tube placed for previous infection.
Figure 1 (A) Preoperative renal ultrasound. (B) Intraoperative retrograde ureteropyelogram demonstrating mid ureteral obstruction. (C) Intraoperative view of mid-ureteral obstruction. (D) Postoperative renal ultrasound 6 months after surgery.
Please cite this article in press as: Bansal D, et al., Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2014.01.029
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Figure 2 Postoperative appearance of hidden incision endoscopic surgery incisions: (A) 1 month after surgery; (B) 4 months after surgery; (C) 6 months after surgery.
Median hospital stay was 1 day (range 1e2 days). One (10%) patient received a regional block. Eight (80%) patients did not receive postoperative narcotics. One patient (5 months of age) received 0.05 mg/kg morphine equivalent per day of hospital stay and another patient (10 months of age) received 0.03 mg/kg morphine equivalent per day of hospital stay. Seven (70%) patients, median age 11.5 months (range 5.5e14.9 months) were administered scheduled postoperative Ketorolac. All patients received scheduled intravenous or oral postoperative Acetaminophen. Median follow-up was 10 months (range 3e18 months). Initial postoperative renal ultrasound was performed at 1e3 months. Renal ultrasound showed improved hydronephrosis in all patients. Three (30%) complications occurred. There were no complications in the two patients that underwent UU. There were two grade I and one grade IIIb complications. The patient with an unstented pyeloplasty presented with a urine leak on postoperative day 4, which was initially managed with a percutaneous nephrostomy tube. An externalized ureteral catheter was placed because of unsuccessful stent placement. Indwelling ureteral stent placement and nephrostomy tube removal were achieved 2 weeks later. One patient was readmitted for ileus on postoperative day 2, managed expectantly, and discharged on postoperative day 4. One patient had a urinary tract infection with an indwelling ureteral stent that was treated with oral antibiotics.
Discussion MIS has become increasingly popular in the management of many pediatric urological conditions, as seen by the increasing number of reports in the literature. However, the evolution of laparoscopic surgical techniques from
extirpative to reconstructive surgery in pediatric urology has been slowed due to the challenge of laparoscopic suturing [5,6]. Robotic technology has allowed surgeons to overcome the limitations of conventional laparoscopy. Wristed instrumentation utilized during robotic surgery has the potential to shorten the learning curve for reconstructive surgery. It opens the door for more surgeons to perform MIS with precise suturing and delicate tissue handling, a skill that may not be achievable for every surgeon due to the limited number of reconstructive procedures any one surgeon may be performing on a consistent basis. Robotic technology has been successfully used in many different pediatric urological procedures. However, there has only been one study of robotic pyeloplasty exclusively in the infant population [10]. Concerns include small patient size for robotic instrumentation, larger trocars, robotic malfunction, costs, and limited benefits over open surgery. To the best of our knowledge, we report the largest series of infant RAL upper urinary tract reconstructive surgery and the first to include UU in infants. Our results are comparable with published data on infant laparoscopic or robotic upper urinary tract reconstructive surgery (Table 1) [9,10,13e18] and infant open pyeloplasty [19e22]. While not explicitly evaluated in our analysis, families verbally expressed satisfaction with the postoperative appearance of the surgical incisions, particularly for patients who had the HIdES technique trocar placement. However, reports assessing patient and family satisfaction with surgical scars between various types of surgical approaches are lacking and further studies are warranted. The operative time in our series was shorter than some and similar to other reports [9,10,13e18]. It is noteworthy that our operative time was similar to that reported in the previous report of infant robotic pyeloplasty [10].
Please cite this article in press as: Bansal D, et al., Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2014.01.029
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Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery Table 1
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Previous reports of infant laparoscopic or robotic reconstructive surgery.
No. infants/total no. patients Median/mean age months (range) Median/mean operative time minutes No. open conversions Median/mean length of stay (days) No. complications (%) No. infant success/total no. infants (%) No. secondary procedures Morphine equivalent usage (mg/kg) Ketorolac usage (mg/kg) No. regional blocks
Turner et al.
Piaggio et al. Kutikov et al.
Neheman Fuchs et al. et al.
Tong et al. Gonzalez et al.
29/29
11/37
8/8
21/21
26/26
23/23
6 (2e11)
61 (0.5e216)
4.5 (3e5) 4 (4e15)
7.3 (2e11)
245
278
108
237
4.4 (not reported) 134
Not 9/9 reported/8 51 (1e190) 5.6 (3e8)
103
211
123
0 1.3
0 2.4
0 1.2
0 2
1 0 Not reported 3
0 3
0 1.4
3 (10.3%) 22/24 (92%) 2 Not reported Not reported Not reported
5 (13.5%) 10/11 (91%)
0 8/8 (100%) 0 Not reported Not reported Not reported
2 (9.5%) 16/17 (94%) 1 0.17
1 (3.8%) 3 (13%) 26/26 (100%) 22/23 (96%) 1 2 Not reported Not reported Not reported Not reported Not reported Not reported
2 (25%) 8/8 (100%)
0 9/9 (100%) 0 Not reported Not reported Not reported
0 0.28 0.36 0
Additionally, operative time in our study was comparable to some but longer than other reports of open pyeloplasty [19e22]. However, the definition for operative time was not clearly reported in all of the previous studies. Our shorter operative than some reports with conventional laparoscopy may be a reflection of benefits provided by robotics. In our series, there no were intraoperative complications or conversions to open or pure laparoscopic surgery. There were three postoperative complications, all of which coincidentally occurred in patients undergoing pyeloplasty. None of the experienced complications were directly related to robotics. An important point in analyzing the benefits of MIS, including robotic surgery in the infant population, is the length of hospitalization and use of postoperative analgesics. The length of stay in our series is similar to previous studies of infant laparoscopic and robotic urological surgery. Postoperative Ketorolac use was comparable to other reports [14,16,17]. Postoperative narcotics and use of regional blocks were lower in our study as compared to these studies. The lack of narcotic use in our series is not easily explained, since larger trocars were used for our robotic procedures than the trocars used with conventional laparoscopy. One potential explanation may be our shorter operative time, which may have decreased postoperative pain due to a shorter duration of abdominal distention. The infants may have also benefitted from utilization of intravenous acetaminophen. Regardless, the difference in overall narcotic use is compelling in validating the use of robotics to perform reconstructive procedures in infants. There are several limitations to this study, including a retrospective design, small patient sample size, single surgeon experience, and lack of a comparison group for outcomes and cost analysis. Despite these limitations, we believe this report substantiates the experience of Kutikov et al. [10]. Our study shows the effectiveness of
Not reported 4
0 0.1 0.5 Not reported
Kutikov et al.
reconstructive upper urinary tract surgery in infants and the potential advantage for treating mid-ureteral obstruction, which may be challenging to address through an open incision if placed in a sub-optimal location. RAL upper urinary tract surgery has the potential to provide a better clinical outcome than open surgery, even in the infant population. All of our patients were at least 5 kg in weight. Weight, as one surrogate for intra-abdominal working space, more than age may be the critical factor in applying robotics to the infant population. Since our study did not include any patients less than 5 kg in weight, the questions remain unanswered for the smallest of infants. Although our study demonstrated beneficial outcomes, future studies are required to validate our findings. Cost has been one of the criticisms of robotic surgery. However, one recent study has reported similar institutional costs for pure laparoscopic and robotic pyeloplasty when accounting for multiple surgeons and ureteral stenting techniques [23]. Another study has reported significantly lower direct costs for RAL urologic surgery than open urologic surgery [24]. The cost difference was primarily due to the difference in duration of hospital stay between patients undergoing open and RAL surgery. And finally, RAL pyeloplasty has also been associated with human capital gains of decreased lost parental wages and lower hospitalization expenses over open pyeloplasty in children [25].
Conclusion Infant RAL upper urinary tract reconstructive surgery is technically feasible, safe, and effective. It can be applied for duplication anomalies and single system obstructions in infants. Further studies are warranted to better define its role compared with open surgery or other alternatives for MIS.
Please cite this article in press as: Bansal D, et al., Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2014.01.029
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Conflict of interest None.
Funding None.
Ethical approval Approval was not required.
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