30th ESPU Congress - Lyon, France - 2019

S8: LAPAROSCOPY & ROBOTICS

Moderators: C. Esposito (Italy), Mohan Gundeti (USA)

ESPU Meeting on Thursday 25, April 2019, 14:00 - 14:48


14:00 - 14:03
S8-1 (PP)

★ LAPAROSCOPY VERSUS ROBOTIC-ASSISTED PYELOPLASTY IN CHILDREN: PRELIMINARY RESULTS OF A RANDOMIZED CONTROLLED TRIAL.

Mesrur Selçuk SILAY 1, Onur DANACIOGLU 1, Kerem OZEL 2, M.Ihsan KARAMAN 1 and Turhan CASKURLU 1
1) ISTANBUL MEDENIYET UNIVERSITY, UROLOGY/DIVISION OF PEDIATRIC UROLOGY, Kadikoy/istanbul, TURKEY - 2) ISTANBUL MEDENIYET UNIVERSITY, PEDIATRIC SURGERY/DIVISION OF PEDIATRIC UROLOGY, Istanbul, TURKEY

PURPOSE

In this randomized controlled trial (RCT), we aimed to compare the outcomes of laparoscopic pyeloplasty (LP) versus robotic-assisted-laparoscopic pyeloplasty (RALP) for UPJO in pediatric population.

MATERIAL AND METHODS

Between January 2017 - April 2018 a total of 33 patients with UPJO were randomized as LP (Group 1, n: 17) and RALP (Group 2, n: 16). Redo cases and patients with anatomical abnormalities were not included. Patients were followed with urinary ultrasound and diuretic renal scintigraphy. Failure was defined as progressive hydronephrosis on ultrasound, obstructive parameters on diuretic renal scintigraphy, decline in renal function, or symptom relapse. All the parameters were statistically compared.

RESULTS

The mean age of the patients were 45.1 (±43.6) months versus 85.8 (±74.2) months for group 1 and group 2 respectively. The mean follow-up period was 9.41 and 7.81 months for group 1 and group 2, respectively (p>0.05). The mean operative times were longer for group 1 (147,6±47,7 minutes) than group 2 (106,5±21,5 minutes) (p=0.004). The hospital stay was similar. Success rates were 94.1% and 100% and comparable for LP and RALP respectively. One failure was defined in group 1 which required redo surgery. A significant improvement was detected in mean anteroposterior diameter and renal parenchyma thickness for both groups.

CONCLUSIONS

The preliminary short term results of this RCT reveals that both LP and RALP are safe and effective in children with comparable success and complication rates. Operative time was longer for LP when compared to RALP.


14:03 - 14:06
S8-2 (PP)

★ LAPAROSCOPIC DISMEMBERED FLAP PYELOPLASTY - THE FIRST SERIES.

Zuzana VALOVA 1, Josef SEDLACEK 2, Vojtech FIALA 2, Marcel DRLIK 2 and Radim KOCVARA 2
1) General Teaching Hospital and Charles University First Faculty of Medicine in Prague, Urology, Prague, CZECH REPUBLIC - 2) General Teaching Hospital and Charles University First Faculty of Medicine in Prague, Department of Urology, Prague 2, CZECH REPUBLIC

PURPOSE

The flap pyeloplasty, mostly non-dismembered, has been reported rarely in English literature. This is the first report of a series of dismembered flap pyeloplasty performed by laparoscopy.

MATERIAL AND METHODS

In a review of 779 patients (aged 0.3-20years), operated for congenital hydronephrosis between 1990 and 2018, we detected 50 patients (6.4%) with flap dismembered pyeloplasty according to Kucera. 29 patients, mean age 4.6ys (0.3-18), had open repair, one bilateral; 21 patients, mean age 8,3ys (1.6-20), had laparoscopic repair. Indications to flap pyeloplasty were: horseshoe kidneys(13), long stenosis(13), intrarenal pelvis or high intrasinusal UP-junction(18), kidney malrotation(14), crossing vessels(26). The ureter is closed and divided at UP-junction and the pelvis is incized from above (V-shape) and flipped caudally. Ureteropyelonefrostomy was mostly used in open repair(26) and JJ-stent in  laparoscopy(16). Mean time after open surgery is 16.9ys and 4.2ys after laparoscopy. Supported by grant RVO-VFN64165.

RESULTS

The operating time in the laparoscopic pyeloplasty was longer, 226(145-435) min., compared to open surgery, 183(120-279) min. (p=0.019). Intraoperative complications occurred in the two first patients operated laparoscopically: unfavorable anatomy with intrarenal pelvis and multiple vessels required conversion to open surgery; and in the second patient extraction of multiple caliceal stones extended the operating time(435 min.). Postoperative complications after open surgery include retrograde stenting due to persistent leakage of urine(1) and dilatation of ureteral stenosis(1); after laparoscopic repair replacement of stents blocked by coagula(2).

CONCLUSIONS

Dismembered flap pyeloplasty is an important technique for specific anatomical conditions, and according to this first series it can be performed safely by laparoscopy. The initial evaluation of the anatomy is crutial for decision to create the flap.


14:06 - 14:09
S8-3 (PP)

OPEN VS ROBOTIC PYELOPLASTY. WHICH ARE THE DIFERENCES?

Sebastian TOBIA GONZALEZ 1, Erika LLORENS DE KNECHT 2, Anabella MAIOLO 1, Yesica GOMEZ 1, J. J. SALAMANCA 2, Yesica QUIROZ MADARRIAGA 2, Ignacio TOBIA GONZALEZ 3 and Anna BUJONS TUR 2
1) Children's Hospital "Sor María Ludivica", Pediatric Urology, La Plata, ARGENTINA - 2) Fundació Puigvert, Pediatric Urology, Barcelona, SPAIN - 3) Universidad Nacional de La Plata, Cátedra de Urología, La Plata, ARGENTINA

PURPOSE

The open dismembered pyeloplasty described by Anderson-Hynes is the gold standard in the treatment of uretero-pelvic junction obstruction. Today, technological development let us perform this surgery with minimally invasive techniques. The objective of this study is compare the results of open (OP) versus robot-assisted pyeloplasty (RAP).

MATERIAL AND METHODS

A retrospective observational comparative study was performed in two centers with 62 OP in center A and 52 RAP in center B. Patient demographics, antenatal hydronephrosis antecedents, kidney function (KF) by MAG3, operating time, hospital stay, complications (Clavien-Dindo), analgesics requirement and functional results were reviewed.

RESULTS

The mean age of the patient was 6,73 year-old. The distribution of gender, laterality, synths or KF by MAG3 didn't differ among groups. The operation time of OP was 110,48 minutes (60-210) and 163,6 minutes for RAP (120-300) (p<0.001). The hospital stay of the OP was 5,24 days (3-13) and for RAP was 3,68 (2-11) (p<0.001). The RAP group needed less analgesics than in the OP group (p>0.001). Postoperative complications weren't statistically different among groups, but the OP had more serious complications than RAP (p<0.03). Postoperative KF was worse in OP patients than RAP with a statistically significant difference (p<0.04). The mean follow up was 61,81 months.

CONCLUSIONS

The RAP required less hospital stay and analgesic needs, greater possibility of KF improvement in postoperative, as well as having milder complications than OP. However, requires more operation times.


14:09 - 14:12
S8-4 (PP)

FEASIBILITY OF LAPAROSCOPIC PYELOPLASTY IN CHILDREN UNDER 1 YEAR OF AGE: A MULTICENTER STUDY.

Francisco REED 1, Ximena RECABAL 1, Florin DJENDOV 2, Javier RUIZ 3, Abraham CHERIAN 2, Roberto VAGNI 4, Francisca YANKOVIC 5, Santiago WELLER 3, Juan Pablo CORBETTA 3, Juan Manuel MOLDES 4, Imran MUSHTAQ 2 and Pedro-Jose LOPEZ 6
1) Exequiel Gonzalez Cortés Hospital, Pediatric Urology, Santiago, CHILE - 2) Great Ormond Street Hospital, Pediatric Urology, London, UNITED KINGDOM - 3) Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Pediatric Urology, Buenos Aires, ARGENTINA - 4) Hospital Italiano de Buenos Aires, Pediatric Urology, Buenos Aires, ARGENTINA - 5) Exequiel Gonzalez Cortés Hospital - University of Chile, Pediatric Urology, Santiago, CHILE - 6) Hospital Exequiel Gonzalez Cortes & Clinica Alemana, Paediatric Urology, Santiago, CHILE

INTRODUCTION

Anderson-Hynes pyeloplasty is the preferred technique in management of ureteropelvic junction obstruction (UPJO) with excellent success rate. Classically, approach is through lumbotomy or anterior incision. Although minimally invasive approach has shown comparable results, its application in young children has not been universally accepted. Aim of study was to analyze experience of 4 centers with laparoscopic pyeloplasty (LP) in children under 1year of age.

MATERIAL AND METHODS

Retrospective study of all infants under 1 year of age who underwent LP between 2009 and 2017 at 4 international pediatric urology centers. Evaluation included ultrasound and renogram before and after surgery. Demographic data, perioperative characteristics, complications and results are described.

RESULTS

In 9 years, out of 327 transperitoneal LP, 42 procedures were performed in patients under 1 year (35 males). Two cases bilateral UPJO. 12/44 renal units were right-sided. 70% had prenatal diagnosis (n31). At surgery average age was 6 months (1-12 months) and 64% (n27) were under 6 months ofº age. Average weight was 8kg (5-10kg), 31% (n13) less than 7kg. Average operative time was 145min (75-230min). After mean follow up of 22.5 months (4-75months), 2 (4.5%) patients developed complications. One developed recurrence of UPJO, requiring redo LP and other required nephrectomy due to progressive renal function deterioration.

CONCLUSIONS

LP in children under 1 year old has similar results to older children. Once experience has been achieved in LP, age and weight have ceased to be a limiting factor, gaining strength and popularity in all pediatric age groups with comparable results as classical AH pyeloplasty.


14:12 - 14:15
S8-5 (PP)

LAPAROSCOPIC LICHTENBERG PROCEDURE IN INFANTS WITH UPJO

Galina KUZOVLEVA
Speransky Children's Hospital №9, Urology departament, Moscow, RUSSIAN FEDERATION

PURPOSE

To prove the advantages and evaluate the results of laparoscopic Lichtenberg procedure in children with UPJO of the first year of life with high inserted ureter

MATERIAL AND METHODS

We compared two groups of children aged 3 to 12 months. The first group (39 patients) underwent laparoscopic Lichtenberg procedure (non-dismembered pyeloplasty with a longitudinal side-to-side anastomosis). In the second group (31 patients) laparoscopic Hynes-Anderson pyeloplasty was preformed.
The criteria for comparison of two groups were the mean time of operation, learning curves, the frequency of postoperative complications and the results of treatment. To assess the level of complexity of the operation, the learning curves for Lichtenberg and Hynes-Anderson procedures were compared.
To determine the learning curve, we fitted a non-linear regression of a point set with every point representing the duration of the unilateral laparoscopic Lichtenberg and Hynes-Anderson procedures.

RESULTS

It was established that the learning plateau (the shortest possible surgery duration) was 97±30.6 and 67.8±30.9 minutes (p=0.0001) for Hynes-Anderson and Lichtenberg procedures respectively.
According to our data, the surgeon needs to carry out 15 Hynes-Anderson procedures to reach the 96 % potential (reflecting the corresponding learning rate). When performing the Lichtenberg procedure the learning curve from the first operation had the form of a plateau, which proves that it is easier to perform.
Success rates were 98% and 96.4% in group 1 and group 2 respectively. No complications were observed in both groups.

CONCLUSIONS

Laparoscopic Lichtenberg procedure is ergonomic, efficient and doesn't require significant time.
In this regard, it can be recommended for an infant with UPJO and high inserted ureter.


14:15 - 14:30
Discussion
 

14:30 - 14:33
S8-6 (PP)

[CANCELLED] LAPARSCOPIC TRACTION VS STAGED LAPARSOPIC FOWLER STEPHENS IN MANAGING INTRA ABDOMINAL TESTES

Waleed DAWOOD 1, Mohamed YOUSSIF 2, Haytham BADAWY 2, Ahmed FAHMY 2, Assem GHOZLAN 2 and Samir ORABI 2
1) Alexandria faculty of Medicine, Faculty of Medicine, Alexandria, EGYPT - 2) Alexandria faculty of Medicine, UROLOGY, Alexandria, EGYPT

PURPOSE

Staged laparoscopic Fowler Stephens orchiopexy is the most popular method for managing intra-abdominal testis with a success rate of 50–86 % .laparoscopic traction for managing intra-abdominal testis is an old technique that had undergone some modifications in the last years. We compared both techniques to evaluate the success and limitation of each of them.

MATERIAL AND METHODS

Forty Patients were enrolled in our study .Age ranges from 8-98 months and technique was chosen randomly. techniques are Fowler Stephens staged laparoscopic orchiopexy and staged laparoscopic traction orchiopexy.

RESULTS

Success rate of Staged Laparoscopic Fowler Stephens orchiopexy in relation to the site of the testis 6 months postoperatively 78.9%and in relation to size 68.4 %, one case was found atrophied at the time of 2nd stage and for traction was 85% and 70 % with no statistical significance. Operative time is lower in 1st stage of Fowler Stephens and lower in 2nd stage in laparoscopic traction and it was statistically significant in both 1st and 2nd stage In children >60 monthsFowler Stephens orchiopexy was better than laparoscopic traction. There was no statistical difference between both techniques in relation distance of the testis from the internal ring, ring open or closed and age of the patient at first stage.

CONCLUSIONS

Laparscopic traction for managing intrabdominal testis is comparable toStaged laparoscopic Fowler Stephens orchiopexy .Site of the testis from the internal ring, ring open or closed and age of the patient don’t affect the results of both techniques. the overall operative time is comparable.


14:33 - 14:36
S8-7 (PP)

3 YEARS ON - REALISING THE BENEFITS OF CUSUM ANALYSIS IN ROBOTIC SURGICAL PRACTICE

Alexander TURNER and Ramnath SUBRAMANIAM
Leeds Children's Hospital, Department of Paediatric Urology, Leeds, UNITED KINGDOM

INTRODUCTION

The learning curve is an important method of assessment of progression in the use of a new technique or device. Unlike case duration curves, cumulative summation curves (CUSUM) monitor process changes and calculate the number of cases required to leave the learning phase. Basic data was presented previously; now we have interpreted inflection and transition points in the curves with interesting results. We show a single surgeon's entire robotic CUSUM data for docking time (all operations) and surgical time (pyeloplasty).

MATERIAL AND METHODS

The time from first skin incision to robotic docking (docking time) for the first 137 robotic cases and the time from robot start to robot finish (operative time) for the first 37 pyeloplasties were collected prospectively. Raw and CUSUM data were found and plotted, with learning durations calculated and inflection points analysed. Statistical analysis compared initial learning and maintenance phases.

RESULTS

A classical learning curve of approximately 30 and 13 cases was found for docking time and pyeloplasty respectively, with statistically significant reductions in time between learning and maintenance phases (p<0.001 and p=0.01). Graph inflections were analysed and corresponded to important events and process changes experienced by the team, such as learning new skills or the use of new equipment. New learning curves appeared in response to these changes.

CONCLUSIONS

CUSUM analysis is vital in the interpretation of learning curves and pinpointing the effects of changes in practice and can be applied similarly to technical and surgical components. It is fascinating to be able to account for real-life events and the effects they have on performance, which can only be seen on CUSUM graphs. These enable teams to track training and attainment accurately.


14:36 - 14:39
S8-8 (PP)

LAPAROSCOPIC NEPHRECTOMY IN CHILDREN: STONE OR NO STONE. DOES IT REALLY MATTER?

Sadaf ABA UMER KODWAVWALA, Sajid SULTAN, Bashir AHMED, Philip G. RANSLEY and Adeeb-Ul-Hassan RIZVI
SINDH INSTITUTE OF UROLOGY AND TRANSPLANTATION, Philip G. Ransley Department of Paediatric Urology, Karachi, PAKISTAN

PURPOSE

To compare the perioperative parameters and outcome of laparoscopic nephrectomy (LN) in children with and without urinary stone disease (USD).

MATERIAL AND METHODS

Retrospective analysis of medical records of children who underwent LN for non-functioning kidney between June 2011-December 2017. On the basis of etiological factors children were divided in two groups. Group I: Children with stone disease (USD), Group II: Children with non-stone disease (NSD). Data was analysed on SPSS v.20. T- test and Chi- square tests were used for statistical analysis. P=<0.05 was considered significant.

RESULTS

Total 249 laparoscopic nephrectomies were done between 2011 and 2017. Group I included 110 and Group II – 139 children. Children in Group II were comparatively younger than Group I, 7.9 vs.10.1y (p<0.0001). Boys were more in Group II (77% vs.59%) - p=0.004. Right sided nephrectomies were more in Group I (62% vs. 45%) - p= 0.008. Use of approach; Transperitoneal vs. retroperitoneal, duration of surgery, mean haemoglobin drop and need of blood transfusion were not statistically different in both groups (p=0.73, p=0.9, p=0.41, p=0.15 respectively). Children with USD were more with Percutaneous nephrostomy preoperatively for pyonephrosis than Group II (23.7% vs. 4.1%) p<0.0001.  Complication rates were slightly higher in Group I (21.5% vs12.5%) but statistically not significant(p=0.07). Elective conversion to open was 13.6 % in Group I vs. 6.1% in Group II (p=0.05). Xanthogranulomatous pyelonephritis was found in 7.3% of histopathology.

CONCLUSIONS

Non-functioning kidney with or without stone disease can be operated safely with laparasocopic nephrectomy with comparable complication rates.


14:39 - 14:48
Discussion