Letters to the Editor Re: Completely Intracorporeal Robotic-assisted Laparoscopic Augmentation Enterocystoplasty With Continent Catheterizable Channel (Urology 2014;84:1314-1318) TO THE EDITOR:
Recently, there was a growing interest for roboticassisted laparoscopic approach to achieve reconstructive urologic procedures among pediatric and adult neurologic patients.1-4 In a recent article, Flum et al5 reported the feasibility of complete intracorporeal robotic-assisted laparoscopic augmentation cystoplasty with continent urinary diversion among adult neurologic patients.5 The authors reported potential benefits regarding the effectiveness and the morbidity including cosmetic aspects, decreased time to return of bowel function, shorter duration of postoperative hospitalization, and improved urodynamic parameters. However, we felt that some data are missing from the present report to evaluate the technique appropriately. First, a short hospital stay is not a relevant outcome since the surgical department stay only depends on the rehabilitation department availability to receive neurologic patients in the postoperative period. Furthermore, we did not get any information about the duration of postoperative indwelling urinary catheterization. The evaluation of functional outcomes obtained after an augmentation cystoplasty with or without continent catheterizable tube has to include continent tube complications (eg, stenosis or false passage), continence achieved by the stoma or by the urethra, kidney function, and quality of life. In the present study, to assess the functional outcomes of the surgery, only urodynamic data were reported; they showed a compliant reservoir with good capacity. Furthermore, although a mean follow-up of 38.9 months (range, 6.2-72.1 months) was available, only early postoperative complications (13 hours, and 2 pulmonary emboli and 1 deep venous thrombosis were reported. We cannot agree that it is acceptable to spend 13 hours in the operating room only to meet a pure laparoscopic challenge. Ideally, prospective controlled studies have to be built up to evaluate laparoscopic-robotic approach opposed to conventional approach and show at least a noninferiority of the technique concerning outcomes and morbidity. One has to understand that this is a challenging surgery regardless of the surgical approach chosen. We could recommend that a huge past experience of open procedures should be a prerequisite to start robotic approach to perform this kind of surgeries. It is our own ethical policy as regards the risks undertaken for the patients. To intend to perform complex and technical challenging surgeries is to determine whether you can expect or not a benefit for the patient. Veronique Phe, M.D. Morgan Rouprêt, M.D., Ph.D. Emmanuel Chartier-Kastler, M.D., Ph.D. Department of Urology Pitie-Salpetrière Academic Hospital Assistance Publique-Hôpitaux de Paris Pierre and Marie Curie Medical School Paris 6 University Paris, France
References 1. Famakinwa OJ, Rosen AM, Gundeti MS. Robot-assisted laparoscopic Mitrofanoff appendicovesicostomy technique and outcomes of extravesical and intravesical approaches. Eur Urol. 2013;64: 831-836. 2. Gundeti MS, Acharya SS, Zagaja GP, Shalhav AL. Paediatric roboticassisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy (RALIMA): feasibility of and initial experience with the University of Chicago technique. BJU Int. 2011;107:962-969. 3. Wille MA, Zagaja GP, Shalhav AL, Gundeti MS. Continence outcomes in patients undergoing robotic assisted laparoscopic Mitrofanoff appendicovesicostomy. J Urol. 2011;185:1438-1443. 4. Rey D, Helou E, Oderda M, et al. Laparoscopic and robot-assisted continent urinary diversions (Mitrofanoff and Yang-Monti conduits) in a consecutive series of 15 adult patients: the Saint Augustin technique. BJU Int. 2013;112:953-958. 5. Flum AS, Zhao LC, Kielb SJ, et al. Completely intracorporeal robotic-assisted laparoscopic augmentation enterocystoplasty with continent catheterizable channel. Urology. 2014;84:1314-1318.
0090-4295/15
205
Recently, there was a growing interest for roboticassisted laparoscopic approach to achieve reconstructive urologic procedures among pediatric and adult neurologic patients.1-4 In a recent article, Flum et al5 reported the feasibility of complete intracorporeal robotic-assisted laparoscopic augmentation cystoplasty with continent urinary diversion among adult neurologic patients.5 The authors reported potential benefits regarding the effectiveness and the morbidity including cosmetic aspects, decreased time to return of bowel function, shorter duration of postoperative hospitalization, and improved urodynamic parameters. However, we felt that some data are missing from the present report to evaluate the technique appropriately. First, a short hospital stay is not a relevant outcome since the surgical department stay only depends on the rehabilitation department availability to receive neurologic patients in the postoperative period. Furthermore, we did not get any information about the duration of postoperative indwelling urinary catheterization. The evaluation of functional outcomes obtained after an augmentation cystoplasty with or without continent catheterizable tube has to include continent tube complications (eg, stenosis or false passage), continence achieved by the stoma or by the urethra, kidney function, and quality of life. In the present study, to assess the functional outcomes of the surgery, only urodynamic data were reported; they showed a compliant reservoir with good capacity. Furthermore, although a mean follow-up of 38.9 months (range, 6.2-72.1 months) was available, only early postoperative complications (13 hours, and 2 pulmonary emboli and 1 deep venous thrombosis were reported. We cannot agree that it is acceptable to spend 13 hours in the operating room only to meet a pure laparoscopic challenge. Ideally, prospective controlled studies have to be built up to evaluate laparoscopic-robotic approach opposed to conventional approach and show at least a noninferiority of the technique concerning outcomes and morbidity. One has to understand that this is a challenging surgery regardless of the surgical approach chosen. We could recommend that a huge past experience of open procedures should be a prerequisite to start robotic approach to perform this kind of surgeries. It is our own ethical policy as regards the risks undertaken for the patients. To intend to perform complex and technical challenging surgeries is to determine whether you can expect or not a benefit for the patient. Veronique Phe, M.D. Morgan Rouprêt, M.D., Ph.D. Emmanuel Chartier-Kastler, M.D., Ph.D. Department of Urology Pitie-Salpetrière Academic Hospital Assistance Publique-Hôpitaux de Paris Pierre and Marie Curie Medical School Paris 6 University Paris, France
References 1. Famakinwa OJ, Rosen AM, Gundeti MS. Robot-assisted laparoscopic Mitrofanoff appendicovesicostomy technique and outcomes of extravesical and intravesical approaches. Eur Urol. 2013;64: 831-836. 2. Gundeti MS, Acharya SS, Zagaja GP, Shalhav AL. Paediatric roboticassisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy (RALIMA): feasibility of and initial experience with the University of Chicago technique. BJU Int. 2011;107:962-969. 3. Wille MA, Zagaja GP, Shalhav AL, Gundeti MS. Continence outcomes in patients undergoing robotic assisted laparoscopic Mitrofanoff appendicovesicostomy. J Urol. 2011;185:1438-1443. 4. Rey D, Helou E, Oderda M, et al. Laparoscopic and robot-assisted continent urinary diversions (Mitrofanoff and Yang-Monti conduits) in a consecutive series of 15 adult patients: the Saint Augustin technique. BJU Int. 2013;112:953-958. 5. Flum AS, Zhao LC, Kielb SJ, et al. Completely intracorporeal robotic-assisted laparoscopic augmentation enterocystoplasty with continent catheterizable channel. Urology. 2014;84:1314-1318.
0090-4295/15
205
