ESPU Meeting on Friday 10, June 2022, 13:25 - 14:20
Marianne ALAM, Venusia FIORENZA, Aline BROCH, Nathalie BOTTO, Henri LOTTMANN and Thomas BLANC
Hôpital Necker Enfants Malades, Department of Paediatric Surgery and Urology, Paris, FRANCE
Robotic-asssited renal surgery has become an accepted approach in pediatric urology. We present our experience in retroperitoneal robotic renal surgery in children during the past 5 years in selected cases. We evaluate our series to establish feasibility, safety, and efficacy in children.
MATERIAL AND METHODS
Prospective study (NCT03274050) since November 2016. We performed 92 retroperitoneal robotic renal procedures on children: 84 pyeloplasties, 4 partial nephrectomies for malignancies and 4 renal cyst unroofing for symptomatic large renal cysts. Patient data, operating room parameters and postoperative course were recorded.
The median age was 7 years (5.1-12.2); the youngest was 20-month-old. The median weight was 25 kg (17-37) with the smallest weighing 10 kg.
All procedures were completed with the robotic approach. Intraoperative blood loss was minimal. No redo procedure has been necessary.
The most common complications were related to the double J stent for pyeloplasty. 90% of children with RRALP were discharged on day one and 14 children were managed on same day surgery.
For partial nephrectomy, macroscopic complete resection (R0) was achieved in all children. Neither recurrence nor medium-term complications occurred.
Median follow-up was 34 months (29-39). No long-term complications occurred.
After standardization of the approach, retroperitoneal robotic renal surgery in selected children is feasible, safe and effective in ablative surgery, reconstructive surgery and surgical oncology, with minimal morbidity, minimal postoperative discomfort, improved cosmetic results, and a short hospital stay. It is an excellent option with ideal anatomical exposure.
Aline BROCH 1, Annabel PAYE-JAOUEN 2, Béatrice BRUNEAU 3, Pauline LOPEZ 2, Mary HIDALGO 4 and Thomas BLANC 1
1) Hôpital Necker Enfants malades, Service de chirurgie viscérale et urologie pédiatrique, Paris, FRANCE - 2) Hôpital Robert Debré, Service de chirurgie viscérale et urologie pédiatrique, Paris, FRANCE - 3) Hôpital Robert Debré, Service d'anesthésie pédiatrique, Paris, FRANCE - 4) Hôpital Necker Enfants malades, Service d'anesthésie pédiatrique, Paris, FRANCE
Robotic surgical procedures have become common in pediatric urology. Retroperitoneal approach for ureteropelvic junction obstruction can be performed robotically with only limited trauma for the children, making its performance in an ambulatory setting potentially interesting.
The aim of this study is to report our preliminary experience with ambulatory retroperitoneal robotic-assisted laparoscopic pyeloplasty (R-RALP).
MATERIAL AND METHODS
The PECRoP study was conducted prospectively in 2 academic children hospital (NCT03274050). A clinical pathway and prospective research protocol were specifically set up to establish and assess the routine use of same day discharge (SDD) R-RALP.
Primary outcomes were same day discharge failure, and 30-day Clavien-Dindo complication and readmission rates.
Secondary outcomes included preoperative characteristics, perioperative parameters, pain visual analogue scale at discharge and follow-up.
Since May 2020, 20 children were consecutively selected for SDD/R-RALP.
Mean age was 8.6 years (2.3-13.3). Mean weight was 31 kg (13-60). Mean operative time was 184 min (122-275). Mean console time was 129 minutes (66-210).
There were no operative complications or conversion.
Four children were kept under observation overnight and discharged the following day due to parental anxiety (n=2); persistent pain (n=1); long procedure (n=1)
The average duration of hospital stay of the 16 children in SDD setting was 12 hours (9.5-14).
One postoperative complication occurred: urinoma in a 2-year-old girl with no JJ stent (Clavien Dindo IIIb)
This prospective case series is the first to demonstrate the feasibility and safety of SDD/R-RALP in children. For selected patients and through a dedicated, clinical pathway, it provided excellent results.
Further evaluation is warranted to assess children and parent satisfaction and expected benefits on healthcare cost savings.
Aznive AGHABABIAN, Sonam SAXENA, Sahar EFTEKHARZADEH, Katherine FISCHER, John WEAVER, Sameer MITTAL, Christopher LONG, Dana WEISS, Arun SRINIVASAN and Aseem SHUKLA
Children's Hospital of Philadelphia, Department of Surgery, Division of Urology, Philadelphia, USA
Maintaining stable pneumoperitoneum, smoke clearance, and visualization during minimally invasive surgery is important for minimizing intra and post-operative complications. Airseal® is a recently introduced insufflation alternative that recirculates and continuously cleans the air using a high-flow system. While Airseal® use in adults is expanding, reports on its’ use in pediatrics are lacking. Our aim was to evaluate the efficacy of Airseal® as in insufflation alternative during robot-assisted laparoscopic pyeloplasty (RALP) in pediatrics. We hypothesize that Airseal® is associated with comparable outcomes to the traditional insufflation method.
MATERIAL AND METHODS
An IRB approved single-institutional registry was utilized to retrospectively identify patients undergoing RALP between 2018-2021. Patients were divided into two groups: traditional insufflation and Airseal®. Patients over 18 years old or those with redo/bilateral pyeloplasty, malrotated kidney, horseshoe kidney, or Y-duplication were excluded. Intra-operative anesthesia parameters/complications, urologic symptoms reported within 7 days of surgery, 30-day complications, and intra- and post-operative opioid use was aggregated.
Of the 110 patients undergoing RALP, 88 patients (80%) met inclusion criteria: 51 (58%) in Group 1 (traditional) and 37 (42%) in Group 2 (Airseal®). We found no difference in intra-operative anesthesia parameters, 30-day complications, length of procedure and stay, and patient-reported symptoms within 7 days of surgery.
Our results are the first to demonstrate the safety of Airseal® continuous insufflator system in a pediatric cohort undergoing laparoscopic surgery. Based on this pilot study, an ongoing trial is assessing whether Airseal® facilitates lowering of insufflation pressure without compromising visualization to reduce median peak pressure and end tidal CO2.
Andrew SHUMAKER 1, Leon CHERTIN 1, Sergei BONDARENKO 2, Kobi STAV 1 and Amos NEHEMAN 1
1) Shamir Medical Center, Department of Urology, Beer Yaakov, ISRAEL - 2) Regional Clinical Hospital 7, Department of Pediatric Urology, Volgograd, RUSSIAN FEDERATION
Failure after open ureteral reimplantation has been reported to occur in 2-7% of cases. While a second open reconstruction surgery is appropriate in most cases, there are data suggesting similar outcomes utilizing the laparoscopic approach. The purpose of this study is to describe a novel modification and report our experience with laparoscopic ureteral reimplantation after failed open reimplantation utilizing a combined intra and extravesical approach reinforced with a psoas hitch.
MATERIAL AND METHODS
A multi-center, retrospective review of pediatric patients who underwent laparoscopic ureteral reimplantation after failed open surgery between 2012 and 2018 at three different academic centers was performed. Patient demographics, surgical indications, complications and outcomes were reviewed.
Seventeen patients underwent a re-do laparoscopic ureteral reimplantation after failed open surgery. Primary obstructed megaureter was the indication for surgery in 9 cases and vesicoureteral reflux in 8 cases. The median interval between failed open surgery and repeat laparoscopic surgery was 21 months (IQR, 16-36). Median age at surgery was 106 months (IQR, 55-122). Median ureteral diameter before the re-do surgery was 16 mm (IQR, 15-18.5) and after surgery 6 mm (IQR, 4-9), (P<0.001). There were no conversions to open surgery. The overall high grade complication rate (Clavien-Dindo III-V) was 5.9%. During follow-up, low-grade reflux was diagnosed in two cases. Postoperative MAG3 renal scan showed a non-obstructive pattern and stable renal function in all cases.
Laparoscopic reimplantation with incorporation of a psoas hitch after failed open ureteral reimplantation is safe and effective
Amrita MOHANTY 1 and Mohan GUNDETI 2
1) The University of Chicago Pritzker School of Medicine, Chicago, USA - 2) The University of Chicago Comer Children's Hospital, Department of Surgery, Section of Urology, Chicago, USA
We provide a decade of follow-up for our previously published RALIMA technique, focusing on long-term functional and perioperative outcomes.
MATERIAL AND METHODS
Retrospective analysis identified pediatric patients who underwent attempted robot-assisted laparoscopic augmentation ileocystoplasty (RALI) between 2008 and 2021 at a single tertiary center. Outcomes of interest were functional (change in bladder capacity) and perioperative, which included operative time, pain medication use, hospitalization, and complication rates.
Of 29 patients, 25 successfully underwent RALI. 80% underwent concomitant appendicovesicostomy (APV), 44% underwent antegrade continence enema channel formation (ACE), and 20% underwent a bladder neck procedure. Mean operative time was 544 minutes (IQR 465-627). The average return to regular diet was 4.6 days and length of stay was 7.8 days. Mean postoperative narcotic use was 0.45mg/kg/day. Median follow-up was 73 months (IQR 6-125). Mean change in bladder capacity was 245% postoperatively. 2 (8%) Clavien-Dindo grade III complications were noted at 30 days, 4 (16%) were noted at 30-90 days, and 17 (68%) were noted to date. Majority of grade III complications were skin level revision of the stoma (41%), bladder stone removal (29%), and endoscopic visualization of the channel due to difficulty catheterizing (18%). No complications were bowel-related and none required re-augmentation in the follow-up period.
When studying over a decade of follow-up, RALIMA appears to be an alternative approach for neurogenic bladder, demonstrating comparable functional and perioperative outcomes to the published contemporary open series. Operative time continues to be the largest point of criticism with the robotic approach. Further refinements may reduce operative time.
Rim KIBLAWI 1, Andrea ZANINI 2, Benno M. URE 3 and Nagoud SCHUKFEH 1
1) Hannover medical school, Pediatric Surgery, Hannover, GERMANY - 2) Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Pediatric Surgery, Johannsebrug, SOUTH AFRICA - 3) Hannover medical school, Pediatric Sugery, Hannover, GERMANY
Despite the worldwide implementation of laparoscopy in pediatric urology over the last three decades, evidence on its superiority over open surgery is lacking. We assessed the reported advantages and disadvantages of both approaches with focus on complications and evidence grade.
MATERIAL AND METHODS
All published comparative studies of laparoscopic versus open pediatric urologic procedures were searched in PubMed®/MEDLINE® according PRISMA-guidelines. Oncological diagnoses were excluded. Advantages and disadvantages of both approaches were recorded. Evidence grade was assessed according to the Oxford-Evidence-Based-Medicine criteria. Complications were graded according to the Clavien-Dindo classification.
12 randomized-controlled-trials (evidence grade 1b) dealing with three procedure types (inguinal hernia repair, pyeloplasty and varicocelectomy) including 1,478 patients and 104 non-randomized-comparative-studies (evidence grade 2b-3b) dealing with additional five procedure types (nephrectomy, ureteral reimplantation, urachus remnant removal, prostatic utricle removal and orchidopexy) including 139,800 patients were identified. The most frequently reported advantages of laparoscopy were less postoperative pain(82% of studies) and shorter hospital stay(61%). The only frequently reported disadvantage was longer operative time (56%).
Minor complications (Clavien-Dindo grade I-II) were reported for laparoscopy in 4% and for open surgery in 30% of the studies. Moderate complications (Clavien-Dindo grade III) were reported for laparoscopy in 2% and for open surgery in 23% of the studies. No severe complications or mortality (Clavien-Dindo grade IV-V) were reported for both approaches.
High-grade evidence on advantages of laparoscopic versus open urologic procedures is limited. Considerably more complications are reported for open operations. Reports on severe and live threatening complications in pediatric urology are scarce irrespective of the operative technique.
Dario Guido MINOLI 1, Giancarlo ALBO 2, Erika DE MARCO 1, Michele GNECH 1, Carolina BEBI 1, Emanuele MONTANARI 2, Gianantonio MANZONI 1 and A. BERRETTINI 1
1) Fondazione IRCCS Ca Granda -Ospedale Maggiore Policlinico, Paediatric Urology, Milano, ITALY - 2) Fondazione IRCCS Ca Granda -Ospedale Maggiore Policlinico, Urology, Milan, ITALY
In this video we describe our experience in bladder neck plication, robotically assisted, to achieve continence in selected patients.
MATERIAL AND METHODS
In the last three years we performed three robotically assisted bladder neck plication procedures: two females with persistent total incontinence following previous surgeries for ectopic ureters and epispadias and one isolated epispadias in an adolescent male.
For all a laparoscopic robotically-assisted bladder neck plication was electively selected.
The first two procedures were successfully conducted with Da Vinci SI, while in the third case the Da Vinci XI was used. The progressive narrowing of the proximal urethra was always confirmed with combined endoscopic view
All the patients were discharged on 4th post-operative day without complications. A follow-up MCUG confirmed fully preserved spontaneous voiding without post-void residuals and renal US showed persistence of normal upper urinary tracts.
Bladder neck plication has been described successfully as complementary technique in other procedures as robotic radical prostatectomy. Open bladder neck plication, combined with endoscopic control of the urethral lumen, has been used to reach continence in epispadiac females, too.
The anatomical access to the bladder neck region is extremely difficult in open surgery especially in adolescent patients. Robotic access allows a perfect combined endoscopic-laparoscopic approach to the bladder neck area and the firefly vision mode is an extremely useful addition for the correct and precise identification of the urethral segment to be plicated.
Caroline JAMAER, Camille BERQUIN, Tom CLAEYS, Elise DE BLESER, Piet HOEBEKE, Erik VAN LAECKE and Anne-Françoise SPINOIT
Ghent University Hospital, Urology, Ghent, BELGIUM
Pyeloplasty (open or Robot-assisted) is the golden standard when treatment of a symptomatic UPJ stenosis is needed. Sometimes anatomic variants make the procedure challenging. This video describes a step-by-step approach in three settings: a classical crossing blood vessel, a duplicated system and a duplicated system that merges in a Y-shape.
MATERIAL AND METHODS
When pyeloplasty is indicated, the child is put under general anesthesia, in a classical lateral decubitus position. Three trocars are placed. After mobilization of the colon, the renal pelvis is dissected off the surrounding structures.
In all cases, the ureter was subsequently identified, mobilized and hinged on a traction stitch. In anatomic variants, the obstructed moiety is identified. The pyelum and ureter are divided and spatulated according to the Anderson-Hynes technique and anastomosis between the ureter and the renal pelvis is achieved. In variants, the drainage is one of the challenging steps, needing custom-made drainage of both moieties as demonstrated in the video. Correct positioning of the drainage is confirmed with reflux of methylene blue from the bladder.
Total mean surgical time was 93 (minimum 80 - maximum 120) minutes. JJ stent was removed 6 weeks postoperatively in day clinic, additional drainage was removed 1 week after surgery in the outpatient clinic. All three children remain asymptomatic with 10 months of follow-up.
A step-by-step plan for pyeloplasty in case of anatomic variants is presented with a video demonstrating a robot-assisted approach in duplicated systems. Moiety drainage can be challenging.