Robot-assisted Laparoscopic Extravesical Ureteral Reimplantation Research Articles

Robotic ureteral reimplantation and uretero-ureterostomy treating the ureterovesical junction pathologies in children: technical considerations and preliminary results.

Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR) and robotic ureteroureterostomy (RUU) are two mini-invasive surgical techniques that have begun to be performed in pediatric urology in recent years. RALUR has been employed especially for VUR treatment, while RUU is considered principally in case of complex doubled ureteral systems. Our aim is to discuss the safety and feasibility of these approaches in children, focusing on technical considerations and supporting their use in different anomalies and pathologies of the ureterovesical junction. We retrospectively collected data about 58 patients who underwent 44 dismembered RALUR (D-RALUR), 28 non-dismembered RALUR (ND-RALUR) and 5 RUU between May 2020 and December 2021. Indications for surgery were primary or secondary vesicoureteral reflux, megaureter, secondary UVJ obstructions, complicated doubled ureteral systems. Mean age was 3.5years (range 0.6-12.9) and mean weight 17.1 (range 7.2-80). No intraoperative complications occurred nor conversion to open approach were reported. Major postoperative complications were reported in 11.7% of cases with a higher incidence for ND-RALUR. Mean hospital stay was 2.14days (range 1-8). Success rate at the short-term follow-up was 91.9% for D-RALUR, 96.3% for ND-RALUR and 100% for RUU. RALUR and RUU are two feasible and safe procedures to perform in children. RALUR represents the most required and adequate technique in the treatment of UVJ pathologies, however, in selected cases RUU could represent an effective alternative that has to be considered.

Modified technique for robot-assisted laparoscopic infantile ureteral reimplantation for obstructive megaureter

PurposeTo describe a novel modification of technique to improve efficacy of robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) in infants. Materials and methodsBetween April 2017 and July 2019, sixteen infants with primary obstructive megaureter (POM) (Age range: 4–12 months) underwent robot-assisted ureteral reimplantation were reviewed in this series. In addition to the conventional Lich-Gregoir technique, the detrusor tunnel has been extended to the mobilized anterior bladder wall to guarantee sufficient tunnel length/ureter diameter ratio and avoid ureteral angulation. All patients underwent repeated ultrasound, diuretic renal dynamic imaging and voiding cystourethrography (VCUG) perioperatively and the outcomes were documented. ResultsAll operations were completed with robotic assisted approach without conversion. Bilateral and unilateral reimplantation were respectively performed in two and fourteen patients. The mean operative time was 115.0 ± 19.5 min and the mean blood loss was 10.0 ± 1.8 ml. There were no high-grade complications (III–IV on Clavien-Dindo classification) except for one patient. The distal ureteric diameter was reduced from pre operative 1.7 ± 0.5 to 0.6 ± 0.5 cm 6 months post operatively (p < 0.05). One child (6.3%) required the second reimplantation for stenosis. The overall operative success rate was 94.4% (17 of 18 ureters) with a mean follow-up of 15.9 ± 7.4 months with no flux detected. ConclusionOur preliminary experience suggests that our modified robot-assisted laparoscopic extravesical ureteral reimplantation is feasible in infants with good results.

Development and Validation of a Scoring System for Assessment of Clinical Failure after Pediatric Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation: A Multi-Center Study.

We aimed to develop and validate a scoring system as an objective assessment tool for predicting clinical failure after pediatric robotic extravesical ureteral reimplantation. Data for this multi-institutional retrospective cohort was obtained from two tertiary referral hospitals. We defined clinical failure as incomplete radiographic resolution or post-operative febrile UTI. Patients were stratified into low, intermediate, and high-risk groups according to the score. External validation was performed using the model projected to the external validation cohort. An amount of 115 renal units in the development cohort and 46 renal units in the validation cohort were analyzed. The prediction score was calculated with weighted points to each variable according to their regression coefficient as age (year) + BMI + BBD times 10 + VUR grade times 7 + console time (h) + hospital stay times 6. The C-index of our scoring system was 0.850 and 0.770 in the development and validation cohorts, respectively. Clinical failure was significantly different among risk groups: 0% (low-risk), 3.3% (intermediate-risk), and 22.2% (high-risk) (p = 0.004) in the development cohort. A novel scoring system using multiple pre- and intra-operative variables provides a prediction of children at risk of failure after robotic extravesical ureteral reimplantation.

WITHDRAWN: Open versus Robot-assisted Laparoscopic Ureteral Reimplantation: Hospital Charges Analysis and Outcomes at a Single Institution

Robot-assisted laparoscopic extravesical ureteral reimplantation has previously been described as a viable minimally invasive option to open surgery. However, concerns for robotic surgery have been raised owing to assumed higher costs and heterogeneous clinical outcomes. We hypothesized that similar hospital charges and clinical outcomes occur when comparing open and robotic cases in matched cohorts. Open and robotic reimplantation cases from 2013 to 2015 for primary vesicoureteral reflux were matched by age using 1:1 nearest neighbor matching. The matched cohorts were analyzed and compared for their direct itemized hospital charges per surgical case, complications, and clinical outcomes. There were 38 patients in each group after age-matching the 135 patients. Operating room charges were higher for the robotic group compared to the open group (p=0.002), whereas pharmacy and laboratory costs were lower for the robotic group. However, there were no significant differences in total overall charges between the open and robotic groups with cystoscopy or without cystoscopy (p=0.345, p=0.533), since the median hospital stay length was shorter for the robotic group (p<0.001). Clinical success rates were identical for the two groups (open 94.8% vs robotic 94.8%). There were also no significant differences in number of complications between the two cohorts. This is the first age-matched study comparing hospital charges and clinical outcomes of pediatric open and robotic reimplantation. While operating room charges were higher for the robotic cohort, lower hospitalization charges led to comparable overall hospital charges, as well as equivalent clinical outcomes for both cohorts. Level III (Retrospective comparative study) TYPE OF STUDY: Retrospective Study.

Prospective multicenter study on robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV): Outcomes and complications

Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is a minimally invasive alternative to open surgery. We have previously reported retrospective outcomes from our study group, and herein provide an updated prospective analysis with a focus on success rate, surgical technique, and complications among surgeons who have overcome the initial learning curve. To assess the safety and efficacy of RALUR-EV in children, among experienced surgeons. We reviewed our prospective database of children undergoing RALUR-EV by pediatric urologists at eight academic centers from 2015 to 2017. Radiographic success was defined as absence of vesicoureteral reflux (VUR) on postoperative voiding cystourethrogram. Complications were graded using the Clavien scale. Univariate regression analysis was performed to assess for association among various patient and technical factors and radiographic failure. In total, 143 patients were treated with RALUR-EV for primary VUR (87 unilateral, 56 bilateral; 199 ureters). The majority of ureters (73.4%) had grade III or higher VUR preoperatively. Radiographic resolution was present in 93.8% of ureters, as shown in the summary table. Ureteral complications occurred in five ureters (2.5%) with mean follow-up of 7.4 months (SD 4.0). Transient urinary retention occurred in four patients following bilateral procedure (7.1%) and in no patients after unilateral. On univariate analysis, there were no patient or technical factors associated with increased odds of radiographic failure. We report a radiographic success rate of 93.8% overall, and 94.1% among children with grades III-V VUR. In contemporary series, alternate management options such as endoscopic injection and open UR have reported radiographic success rates of 90% and 93.5% respectively. We were unable to identify specific patient or technical factors that influenced outcomes, although immeasurable factors such as tissue handling and intraoperative decision-making could not be assessed. Ureteral complications requiring operative intervention were rare and occurred with the same incidence reported in a large open series. Limitations include lack of long-term follow-up and absence of radiographic follow-up on a subset of patients. Radiographic resolution of VUR following RALUR is on par with contemporary open series, and the incidence of ureteral complications is low. RALUR should be considered as one of several viable options for management of VUR in children.

This Month in Pediatric Urology

No AccessJournal of UrologyThis Month in Pediatric Urology1 Jun 2017This Month in Pediatric Urology Mark P. Cain Mark P. CainMark P. Cain More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.03.095AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "This Month in Pediatric Urology." The Journal of Urology, 197(6), p. 1373 References 1 : A 4-year prospective urological assessment of in utero myelomeningocele repair: does gestational age at birth have a role in later neurogenic bladder pattern?. J Urol2017; 197: 1550. Link, Google Scholar 2 : Multi-institutional review of outcomes and complications of robot-assisted laparoscopic extravesical ureteral reimplantation for treatment of primary vesicoureteral reflux in children. J Urol2017; 197: 1555. Link, Google Scholar © 2017 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 197Issue 6June 2017Page: 1373 Advertisement Copyright & Permissions© 2017 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mark P. Cain More articles by this author Expand All Advertisement PDF downloadLoading ...

Multi-Institutional Review of Outcomes and Complications of Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation for Treatment of Primary Vesicoureteral Reflux in Children

Robot-assisted laparoscopic extravesical ureteral reimplantation has been proposed as a minimally invasive alternative to open ureteral reimplantation for correcting primary vesicoureteral reflux in children. However, in the current literature there are conflicting data regarding the safety and efficacy of this approach. Amid ongoing debate we analyzed outcomes and complications from this procedure in a large multi-institutional cohort. We reviewed the records of children who underwent robot-assisted laparoscopic extravesical ureteral reimplantation at 9 academic centers from 2005 to 2014. Radiographic failure was defined as persistent vesicoureteral reflux on postoperative voiding cystourethrogram or radionuclide cystogram. Complications were graded using the Clavien-Dindo scale. A total of 260 patients (363 ureters) underwent robot-assisted laparoscopic extravesical ureteral reimplantation for primary vesicoureteral reflux during the study period. The cohort included 90 patients with either duplex ureter (42), failed endoscopic treatment (40) or concomitant diverticulectomy (8). Of the 280 ureters with postoperative voiding cystourethrogram or radionuclide cystogram available radiographic resolution was seen in 246 (87.9%). There were 25 complications overall (9.6%), with 7 grade 3 complications (2.7%) and no grade 4 or 5 complications. Four patients (3.9%) had transient urinary retention following bilateral reimplantation. Robot-assisted laparoscopic extravesical ureteral reimplantation has a low complication rate consistent with published series of open ureteral reimplantation. Radiographic success rates are approaching those of the open procedure but continue to fall short of the gold standard approach. These findings necessitate critical thinking regarding potential technique improvements and further prospective investigation into the efficacy of this procedure.

Multi-Institutional Review of Outcomes of Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation

We performed a multi-institutional assessment of the outcomes and complications of robot-assisted laparoscopic extravesical ureteral reimplantation for vesicoureteral reflux in children. We retrospectively reviewed the records of patients who underwent robot-assisted laparoscopic extravesical ureteral reimplantation as done by 1 of 5 surgeons at Children's Medical Center, Dallas, Texas, or Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, from 2010 to 2013. Procedure failure was defined as persistent vesicoureteral reflux on postoperative voiding cystourethrogram or radionuclide cystogram and/or the need for reoperation. Multivariate logistic regression was done to identify possible risk factors for failure using STATA®, version 11. A total of 61 patients (93 ureters) with a mean age of 6.7 years (range 0.6to 18.0) underwent a procedure, of which 32 (52%) were bilateral. Ten patients (16%) underwent previous subureteral injection for vesicoureteral reflux. At a mean followup of 11.7 months the procedure was successful in 44 of 61 patients (72%). There were 14 cases of persistent vesicoureteral reflux (23%), 6 complications (10%) and 9 reoperations (11%). Multivariate logistic regression identified no factor that increased the risk of failure (p = 0.737). Compared to the literature we found a notably lower success rate for robot-assisted laparoscopic extravesical ureteral reimplantation in the hands of 5 fellowship trained, robotically experienced pediatric urologists. More than 10% of patients required at least 1 reoperation for persistent vesicoureteral reflux or a surgical complication. Our experience suggests a higher complication rate and a lower success rate for robot-assisted laparoscopic ureteral reimplantation compared to the gold standard of open reimplantation.

Extravesical robot-assisted laparoscopic ureteral reimplantation for vesicoureteral reflux: initial experience in Japan with the ureteral advancement technique.

To report our initial experience with robot-assisted laparoscopic extravesical ureteral reimplantation using the ureteral advancement technique. A total of 15 ureters from nine patients (age range 2-25 years) underwent robot-assisted laparoscopic extravesical ureteral reimplantation for the management of vesicoureteral reflux. The reflux was classified as grade I in one ureter, grade II in two ureters, grade III in seven ureters, grade IV in three ureters and grade V in two ureters. One of the five female patients had a bilateral duplex system, and reflux was observed in all four ureters. The da Vinci surgical system was utilized. Ureteral advancement was carried out in all cases. We also compared the operative outcomes between conventional laparoscopic procedure and robotic surgery. The console time was 211.5 ± 87.4 min (median ± standard deviation) in the bilateral cases and 144.0 ± 40.8 min in the unilateral cases. Urethral catheters were removed at one or two postoperative days. None of the patients suffered postoperative complications, such as urine leakage or urinary retention. Postoperative voiding cystourethrography showed that the reflux had been resolved in 14 of the 15 ureters (success rate 93.3%). In the remaining case, the reflux grade decreased from III to I. The operative outcomes of robotic surgery were favorable and safe compared with conventional laparoscopic procedure. Our preliminary results showed that robot-assisted laparoscopic surgery is a feasible and useful approach to extravesical ureteral reimplantation, even for patients with bilateral reflux.

Robot-assisted laparoscopic ureteral reimplantation: A single surgeon comparison to open surgery

ObjectiveThe aim was to report a single surgeon's experience comparing open and robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR) to treat vesicoureteral reflux (VUR). Subjects and methodsWe retrospectively reviewed the outcomes of RALUR and open extravesical ureteral reimplantations consecutively performed by a single surgeon between January 2008 and December 2010 using the da Vinci® Surgical System. Both groups of patients were subjected to identical pre- and postoperative care protocols. ResultsDuring the defined study interval, 20 open and 20 RALUR procedures were completed by a single surgeon at our institution. Gender and VUR grade were similar in both cohorts. Operative times were longer in the RALUR group, but postoperative opioid use (morphine equivalents) was significantly lower in the RALUR group (RALUR: 0.14 mg/kg, open: 0.25 mg/kg, p = 0.021). There was no significant difference in estimated blood loss (EBL) or length of hospitalization (LOH). The overall rate of surgical complications was similar; however, the complications in the open group tended to be less severe than those occurring in the RALUR group. On follow-up, after a median of 52 months for open surgery and 39 months for RALUR, two children had developed a febrile urinary tract infection in both groups, of which one in the open group had persistent VUR. ConclusionThis single-surgeon experience of open and initial experience with RALUR performed with the same surgical technique on consecutive cohorts with identical post-surgical care protocol allows a comparative analysis of outcomes for a surgeon transitioning to RALUR. The RALUR reduces postoperative analgesic requirements while yielding similar clinical outcomes as the open technique.