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Current Status of Robotic Pyeloplasty
Table 2: Robotic and Laparoscopic Pyeloplasty in Literature
Number of Surgical Type Operative Anastomosis Success Rate Complication Follow-up Stay (days)
Patients Approach Time (min) (min) (%) Rate (%) (months)
Inagaki et al.
4
147 Transperitoneal Dismembered 246 – 95 8.8 24 –
(106), Fenger
(11), YV (28)
Mendez et al.
23
32 Transperitoneal Dismembered 300 – 100 3.1 10.3 1.1
(31), Fenger (1)
Weise et al.
22
31 Transperitoneal Dismembered 271 76 97 6.4 10 –
Gettman et al.
13
9 Transperitoneal Dismembered 138.8 62.4 100 11.1 4.1 4.7
Siddiq et al.
14
26 Transperitoneal Dismembered 245 – 95 13 6 2
(23), YV (3)
Palese et al.
23
35 Transperitoneal Dismembered 216.4 63 94 5.6 7.9 2.7
Bentas et al.
15
11 Transperitoneal Dismembered 196.8 – 100 0 21 5.5
Palese et al.
18
38 Transperitoneal Dismembered 225.6 64.2 94.7 10.5 12.2 2.8
Patel
12
50 Transperitoneal Dismembered 122 20 100 2 11.7 1.1
is, not much longer than open surgery. Olsen concluded that robotic than 50ml. Mean operative time was 108.3 minutes, decreasing with
retroperitoneal pyeloplasty was easier to learn than standard retro- expertise. The first 12 cases averaged 137.4 minutes, and were longer
peritoneoscopy, leading to a shorter training phase. Atug published a than the last dozen patients (89.76 minutes; p=0.001). This decrease is
similar study in 2005 using a transperitoneal access.
32
In a pilot series of caused by a reduction of docking times and shorter anastomotic times.
seven children (6–15 years), he has reported six being free of obstruction Mean suturing time for the early series was 61.7 minutes, whereas the
while one was awaiting the first control. Operative times were anastomosis was performed in 18.6 minutes in the latter cases (p<0.001).
comparable to retroperitoneoscopy. However, this technique seems to be Average anastomotic time including all cases was 24.8 minutes (see Table
easier to learn due to an extended working space. These two articles 1). Antegrade (laparoscopic) JJ-stent placement was performed in 87,
provided initial evidence that robotic pyeloplasty could be safely while incorrect positioning occurred twice. Those stents were
performed in paediatric patients with similar outcomes as in adults. repositioned using ureteroscopy. Horseshoe kidneys were encountered
Favourable anatomy frequently allows a transmesocolic approach, further twice: Anderson-Hynes pyeloplasty was supplemented by isthmus
speeding up the procedure. transection and lateropexy.
Casale moved another step ahead using robotic pyeloplasty in infants.
33
Limited space challenges the laparoscopist in infants. Nine infants aged
Regarding our extended experience
three to eight months underwent dismembered pyeloplasty without
with robotic pyeloplasty and currently
problems. All children displayed an objective improvement, yielding a
available data, this approach turned out
success rate of 100% in the short term. Operative times were reasonably
short, averaging two hours. Even though open surgery is not problematic to be safe and feasible with many
in neonates, allowing the infant to be discharged home on post-operative
advantages for the patient.
day one, we have to acknowledge that robotic pyeloplasty is feasible and
safe in this population. However, it is not clear if these children truly
benefit from laparoscopy in terms of invasiveness, requiring further During a mean follow-up of 39.1 months, patency rate was 100%. Three
studies. Such a series was published by Lee and co-workers investigating patients experienced complications early after surgery requiring
older children. They demonstrated that open and robotic pyeloplasty had reintervention. One required stent exchange and percutaneous
comparable outcomes, while the laparoscopic group required fewer nephrostomy due to blood clots in the renal pelvis and colic with urine
analgaesics and could leave hospital earlier than the open cohort.
34
extravasation. In one case, haemorrhage into the collecting system
Therefore, we may conclude that robotic laparoscopy is an option for occurred on the second day. Despite initially successful conservative
older children and adolescents, remaining investigational in infants. management, the patient required Culp-de Weerd flap pyeloplasty three
Others have made similar observations and conclusions on that subject.
35
months later. The most severe case occurred due to insufficient closure
of the resected renal pelvis and excessive extravasation. The patient who
At present, the role of robotics in paediatric urology cannot be finally had secondary UPJO underwent transperitoneal exploration and primary
assessed since the development still stands at the very beginning. Cost closure of the renal pelvis. Therefore, the success rate of robotic
will also be a major limitation in this age group. pyeloplasty regarding all patients was 96.7% (89 of 92). In secondary
UPJO cases, the success rate was lower: one out of 12 patients required
Our Experience with Robotic Pyeloplasty re-intervention (success rate 91.7%).
Between 2001 and 2006 92 patients (48 men and 44 women, mean age
35.13 years) underwent robotic, dismembered pyelopasty for UPJO using Average hospital stay was 4.57 days. JJ-stents were removed six weeks
the da Vinci system. All cases were completed laparoscopically without post-operatively. Follow-up intravenous urography at three months
conversion using four transperitoneal ports. Anterior crossing vessels revealed good drainage and a patent anastomosis in all patients. Split
were found and preserved in 45 patients. Suspected blood loss was less renal function improved from 37.63 to 41.88%. There was no late failure
EUROPEAN GENITO-URINARY DISEASE 2007 59
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