5th Joint Meeting of ESPU-SPU - Virtual

S18: LAPAROSCOPY / ROBOTICS

Moderators: Alaa El-Ghoneimi (France)

ESPU-SPU Meeting on Saturday 25, September 2021, 14:00 - 14:42


14:00 - 14:03
S18-1 (PP)

SYNCHRONOUS BILATERAL ADRENALECTOMY FOR RARE CAUSE OF HYPERCORTISOLISM IN CHILDREN: FROM OPEN TO ROBOTIC SURGERY. A SINGLE-CENTER EXPERIENCE OF 27 YEARS

Berenice TULELLI 1, Alix BESANÇON 2, Michel POLAK 2, Sabine SARNACKI 1 and Thomas BLANC 1
1) Necker Enfants-Malades University Hospital, Université de Paris, Paris, France, Department of Pediatric Surgery and Urology, Paris, FRANCE - 2) Necker Enfants-Malades University Hospital, Université de Paris, Paris, France, Department of Pediatric Endocrinology, Paris, FRANCE

PURPOSE

Autonomous secretion of cortisol from the adrenal glands represents approximately 15% of all cases of Cushing's syndrome (CS) in childhood. Particularly rare causes of CS are McCune-Albright syndrome (MAS) and Carney complex (CNC). Surgical strategy is the definitive treatment to correct hypercortisolism and its complications.
Synchronous bilateral adrenalectomy (SBA) represents an exceptional indication. Our aim is to analyze our medical and surgical management of this rare condition.

MATERIAL AND METHODS

Patients who underwent SBA between 1992-2019, were identified. Gender, age, diagnosis, surgical indication, operative time, bleeding, post-operative complications, hospital stay, and outcome were retrospectively analyzed. Bilateral adrenal tumors were excluded.

RESULTS

Nine children were included: 5 MAS, 3 CNC, 1 congenital adrenal hyperplasia. Indications for SBA were non-responsiveness to medical treatment, medical contra-indication, neonatal Cushing's severity and poor control of hyperandrogenism. Mean age at surgery was 3.4 years (1.5 month-9.3 years). SBA was performed by robotic-assisted laparoscopy (n=4), laparotomy (n=2), laparoscopy (n=1), retroperitoneoscopic approach (n=1), and bilateral lombotomy (n=1). Mean length of hospital stay was 25 days. One post-operative complication occurred: a retroperitoneal collection in the adrenal bed, needing percutaneous drainage. At last follow up (mean 6,8 years) all patients were compliant with treatment, no acute adrenal crisis occurred, but seven patients (77%) had CS-related complications

CONCLUSIONS

SBA is a very rare procedure in children and has to be performed in advanced pediatric surgery center. Robotic SBA is a safe and feasible procedure, even in infants. Oral supplementation is life-long therapy that needs strict observance, endocrinology periodic monitoring and education of parents


14:03 - 14:06
S18-2 (PP)

THE EFFECTIVENESS AND SAFETY OF VESICOSCOPIC ACCESS IN INFANTS

Alexander PIROGOV 1, Vladimir SIZONOV 2, Vladimir ORLOV 1 and Mikhail KOGAN 3
1) Regional Children's Hospital, Pediatric Urology, Astrakhan, RUSSIAN FEDERATION - 2) Regional Children's Hospital, Paediatric Urology, Rostov On Don, RUSSIAN FEDERATION - 3) Rostov State Medical University, Urology, Rostov-On-Don, RUSSIAN FEDERATION

PURPOSE

Vesicoscopic access (VA) has not become a frequent practice for 1-year-old children. Low volume of surgical space complicates manipulations inside the bladder making such operations a real challenge in terms of quality and effectiveness.

MATERIAL AND METHODS

VA was used in 217 cases. Group I - 31 children under one year (8.5±2.5 months), 24 (77.4%) operations for vesicoureteral reflux (VUR), 7 (22.6%) - for ureterovesical junction obstruction (UVJO). Group II - 186 patients, mean age: 75.7±49.4 months, 159 (85.5%) VUR, 23 (12.4%) UVJO, and 4 (2.1%) bladder diverticulum cases. In a year, a follow-up VCUG and renal ultrasound examination were performed to check the surgical results. We analysed the duration of operations, conversion frequency, the frequency and severity of complications (graded acc. to Clavien-Dindo).

RESULTS

In group I, conversion was carried out in 1 (3.2%) case, in group II - in 2 (1.0%) cases (p>0.05). Surgery duration in group I was 134.2 minutes, in group II - 131.2 minutes (p>0.05). VUR and UVJO in group I were corrected in 27 (90%), and in group II - in 76 (95.6%) patients (p>0.05). Complications in group I - 13 in 12 (40%) patients, in group II - 24 in 23 (12.4%) patients (p<0.01). Grade 1 complications (acc. to Clavien-Dindo) in group I - 7 (23.3%), in group II - 10 (5.4%) (p<0.01). Grade IIIa complications in group II - 1 (0.5%) patient; IIIb in group I - 3 (10%) patients, in group II - 13 (7%) (p>0.05). Grade IVa complications in group I - 3 (10%). III-IV grade complications among the patients of group I - 6 (20%), in group II - 14 (7.6%) (p<0.05).

CONCLUSIONS

VA in infants is connected with increased frequency and severity of complications limiting its application, particularly during the learning period.


14:06 - 14:09
S18-3 (PP)

THE PATH TO PROFICIENCY FOR ROBOT-ASSISTED LAPAROSCOPIC PYELOPLASTY IN CHILDREN.

Ciro ANDOLFI 1, Tiffany TONI 2, Alyssa LOMBARDO 2 and Mohan GUNDETI 2
1) The University of Chicago, Surgery, Chicago, USA - 2) University of Chicago, Surgery, Chicago, USA

PURPOSE

To report our institutional experience with a robotic approach to pyeloplasty in children, since its adoption.

MATERIAL AND METHODS

We performed a retrospective review of EMR of children with uretero-pelvic junction obstruction (UPJO) undergoing primary RAL-P. We collected data on demographics, skin-to-skin operative time (OT), estimated blood loss (EBL), length of stay (LOS), perioperative complications, and re-intervention due to persistent UPJO. A proficiency jointpoint analysis was performed to group surgical cases into four learning phases.

RESULTS

We identified 133 RAL-P, 102 males and 31 females. Median age at surgery was 57 months (IQR, 6-132). Forty-five patients were infants with a median age of 4 months (IQR, 2.7-6). Mean operative time was 172 minutes (±57). At a median follow up of 13 months (IQR, 3-29), post-operative complications and success rates were 15.8% and 95%, respectively. A jointpoint analysis revealed four learning phases representing progressive improvements in OT, Clavien-Dindo Grade (CDG) III and UPJO re-operation rates (table 1). Accordingly, a decrease of patients age at surgery was noted with increasing surgical experience. 

CONCLUSIONS

This study reveals that the steeper portion of the learning curve can be overcome after about 34 cases (phase 1), with a 75% drop in CDG-III complications, a 50% drop in UPJO re-operation rate, and 63-minute reduction in OT (table 1).

Patients

133

Male gender

102(77%)

Median age at surgery

months(IQR)

57(6–132) 

Mean operative time

minutes(SD)

172(±57)

Median follow up

months(IQR)

13(3–29)

Complications

21(16.5%)

CDG

I

4(3%)

Ileus

II

10(7.5%)

UTI

III 

8(6%)

Urine leak

Port-site hernia

JJ-stent displacement

Success

126(95%)

Learning Phases

Patients

Median age at surgery

Mean OT

CDG-III

Re-Do

Phase1

34

92 (45-152)

224(±69)

4 (12%)

4 (12%)

Phase2

33

67 (6-129)

161(±28)

2 (6%)

2 (6%)

Phase3

33

33 (6-112)

149(±40)

1 (3%)

1 (3%)

Phase4

33

10 (3-167)

139(±26)

1 (3%)

0


14:09 - 14:12
S18-4 (PP)

COMPARISON BETWEEN DOUBLE J STENT AND NEPHROSTOMY IN ROBOTIC PEDIATRIC PYELOPLASTY. A PROSPECTIVE STUDY.

Alexis P ARNAUD 1, Melodie JURICIC 2, Samia LARAQUI 1, Thomas BLANC 3, Marc CHALOUB 2, Coralie DEFERT 1 and Olivier ABBO 2
1) Univ Rennes, CHU Rennes, General Paediatric Surgery and Paediatric Urology department, Rennes, FRANCE - 2) CHU Toulouse, General Paediatric Surgery and Paediatric Urology department, Toulouse, FRANCE - 3) APHP, Université de Paris, General Paediatric Surgery and Paediatric Urology department, Paris, FRANCE

PURPOSE

Robotic approach for pediatric PUJ obstruction is now widely used. However, the type of pelvic drainage is still a matter of debate. We compared the results between JJ stenting and nephrostomy in this indication.

MATERIAL AND METHODS

Patients below 18years prospectively included since 2015. Group JJ: center A, antegrade JJ insertion, removal under GA. Group nephrostomy: center B, nephrostomy insertion, removal in outpatient clinic. In both centers, 1 surgeon using similar transperitoneal approach. Statistical analysis: Student test.

RESULTS

72 patients were included, 36 in each group. Mean age at surgery was 106 ±38 months and 115 ±47 months (p=0.4) in the JJ and nephrostomy groups respectively. Mean duration of JJ stent and nephrostomy insertion was 6min and 11min respectively (p=0.001). No per operative complication. Mean hospital stay was 5 and 2 days respectively (p=0.07). JJ stent was left 32 days vs 13 days for nephrostomy (p<0.001). All but 3 patients (magnetic JJ stent) in the JJ group required GA for stent removal. In the nephrostomy group, 10 complications were noted vs 9 in the JJ group (Table). The success rates (symptoms free and at least same dilatation) was 98,5% (mean follow-up=13months).

 

 

Nephrostomy group

JJ group

Clavien 1

pain

6 lumbar pain at clamping requiring unclamping

2 bladder painful spasms

Healing delay

1 nephrostomy wound healing delay

0

Clavien 2

UTI

2

4

Urinary retention

0

1

Clavien 3b

Stent problem

1 nephrostomy dislodgement requiring JJ insertion

1 stent blockage requiring ureteroscopy (magnetic JJ)

1 anastomotic leakage (magnetic JJ)

Secondary GA

1 (3%)

34 (94%)

CONCLUSIONS

In our experience, nephrostomy have been associated with lower Clavien grade complications than JJ stents, with the main advantage to avoid second GA for the removal. Magnetic JJ stents might certainly represent the future but to date led to severe complications in children.


14:12 - 14:24
Discussion
 

14:24 - 14:27
S18-5 (PP)

CONTINENT CUTANEOUS CATHETERIZABLE CHANNELS IN PEDIATRIC PATIENTS: A SINGLE CENTER DECADE OF EXPERIENCE WITH OPEN AND ROBOTIC APPROACHES.

Ciro ANDOLFI 1, Logan GALANSKY 2 and Mohan GUNDETI 3
1) The University of Chicago, Surgery, Chicago, USA - 2) University of Chicago, Chicago, Chicago, USA - 3) University of Chicago, Surgery, Chicago, USA

PURPOSE

To describe our progressive advancement from open to robotic performance of CCCs, reporting and comparing outcomes between the two approaches.

MATERIAL AND METHODS

We retrospectively reviewed electronic medical records of pediatric patients who underwent construction of CCCs between 2008 and 2019. The types of channel performed were appendicovesicostomy (APV), Monti with tapered ileum, and/or antegrade colonic enema (ACE) without cecum imbrication. We compared open versus robotic approaches for patient demographics, comorbidities, intraoperative data, and postoperative outcomes, such as continence and complications.

RESULTS

A total of 69 patients were included in this analysis, with 35 and 34 patients in the open and robotic group, respectively. The robotic approach showed a significant decrease in days required to return to regular diet (6.8 vs 12.6 days, P=0.0084) and almost 50% reduction in LOS as compared to the open approach (6.8 vs 12.6 days, P=0.0097). Operative time (OT) was longer for robotic procedures (444 vs 307 min, P=0.0006). When excluding patients undergoing bladder augmentation, OTs were similar between the two groups, regardless of the channel type [292 (±59) vs 294 (±154), P=0.9652]. At a median follow-up of 75 months (43-104), 28 patients (40.6%) presented with postoperative complications-15(42.9%) open and 13(38.2%) robotic. Continence rates were 91.4% and 91.2% for open and robotic approaches (P=0.7724), respectively.

CONCLUSIONS

Robotic surgery for CCCs showed acceptable postoperative outcomes and complication rates, which are comparable to the traditional open approach. Additionally, due to its minimally invasive nature, it offers advantages such as decreased postoperative pain, LOS, time to full diet, and better cosmesis. As more surgeons implement the use of a robotic platform into their practice, the optimization of surgical steps for CCCs will further reduce operative times, making this already safe and effective approach a more sustainable operative modality.


14:27 - 14:30
S18-6 (PP)

ROBOTIC ASSISTED LAPAROSCOPIC PYELOPLASTY FOR URETEROPELVIC JUNCTION OBSTRUCTION IN CHILDREN: A MULTICENTER PROSPECTIVE STUDY COMPARING THE TRANSPERITONEAL APPROACH AND RETROPERITONEOSCOPY.

Thomas BLANC 1, Olivier ABBO 2, Caroline ELIE 3, Mélodie JURICIC 2, Samia LARAQUI 4, Fabrizio VATTA 1 and Alexis ARNAUD 4
1) Hopital Necker- Enfants Malades, Service de Chirurgie Viscérale et Urologie Pédiatriques, Paris, FRANCE - 2) CHU de Toulouse, Service de Chirurgie Viscérale et Urologie Pédiatriques, Toulouse, FRANCE - 3) Centre d'investigation Clinique Paris Descartes - Necker - Cochin, Unité de Recherche Clinique, Paris, FRANCE - 4) CHU de Rennes - Université de Rennes, Service de Chirurgie Viscérale et Urologie Pédiatriques, Rennes, FRANCE

PURPOSE

Robot-assisted laparoscopic pyeloplasty (RALP) has been gaining acceptance among pediatric urologists. Our aim was to compare the results and complications of RALP using transperitoneal (TRALP) and retroperitoneal approaches (RRALP).

MATERIAL AND METHODS

A 3-year prospective study (NCT03274050) was performed in 3 centers (2 for transperitoneal approach and one for retroperitoneoscopy) from 11/2016 to 11/2019. Dismembered pyeloplasty and anastomosis were performed using running monofilament 6-0 absorbable suture. All were drained by double-J stent or external transanastomotic stent. Data were analysed comparatively.

RESULTS

103 children were operated (RRALP n=53; TRALP n=50). The preoperative data of both groups were comparable. Median age and weight were 9 years (2-19) and 26 kg (13-124) respectively.
Set up time, anastomotic time and console time were significantly longer in the retroperitoneoscopic group (31 min vs 10 min; 73 min vs 50 min; 153 min vs 98 min respectively; p<0,001). None of the patient parameters apart from the approach had a significant impact on operative time. No conversion to an open operation was necessary. Median hospital stay was shorter in the retroperitoneoscopic group (1 day vs 2 days; p<0,001). Complication rates were similar (RRALP, 11% vs TRALP, 20%) but Clavien IIIb were more common in TRALP (p<0.008). No failure occurred at mean follow up of one year (2-29 months).

CONCLUSIONS

RALP is as safe and effective procedure in children with transperitoneal approach or retroperitoneoscopy. Even if the procedure is longer with retroperitoneoscopy, hospital stay and complications seems to be reduced with this approach. A longer term follow-up is awaited.


14:30 - 14:33
S18-7 (PP)

SIMPLE RENAL CYSTS: COMPARISON OF LAPAROSCOPIC DEROOFING AND PERCUTANEOUS SCLEROTHERAPY IN CHILDREN

Deying ZHANG, Xing LIU, Dawei HE and Guanghui WEI
Children's Hospital of Chongqing Medical University, Urology, Chongqing, CHINA

PURPOSE

To evaluate laparoscopic deroofing (LDR) and percutaneous sclerotherapy (PCS) in the treatment of simple renal cysts.

MATERIAL AND METHODS

17 patients with simple renal cysts administrated in our hospital during Sep 2017 and Sep 2019 were divided into 2 groups randomly. 9 patients in Group 1 were operated with LDR, 8 patients in group 2 were treated with PCS under guidance of ultrasound. The age of the patients ranged from 2 to 12.5 years old. The diameter of the cysts ranged from 4.1cm to 7.8cm. 8 patients claimed flank pain, while 9 patients with no symptoms. Patients in PCS group were administrated with dehydrated alcohol with the same volume of original cyst for 10min X 3 times; methylene blue tests were performed to exclude cysts communication with collecting system before dehydrated alcohol injection.

RESULTS

The operation time of LDR ranged from 28min to 85min, averaged at 37min, with tracheal intubation anesthesia; PCS group were 5min to 13min, averaged at 8min, with intravenous anesthesia combined with lidocaine local anesthesia. Postoperative stay in hospital were 3 days in LDR group and 1 day in PCS group. No obvious postoperative complications in both groups. Average total hospitalization expense of PCS was 72% compared to LDR. Patients were followed up for 4 months to 2 years. No recurrence was found after LDR, 1 residual cyst of 1.5cm in diameter was found 3 months after PCS without increase during 12 months further follow up.

CONCLUSIONS

Both LDR and PCS are safe and effective for renal cysts in children; compared to LDR, PCS is more minimal invasive and less cost, can be used as first choice in treatment.


14:33 - 14:42
Discussion