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during an extended follow-up period. Correspondingly, no patient has disadvantage in cost-effectiveness, with robotics being 2.7 times more
had recurrent flank pain, pyelonephritis or renal colic after pyeloplasty. expensive. However, these results are based on extremely refined
laparoscopic skills, with Link’s institution being one of the most
The Matter of Cost and Conventional Laparoscopy renowned in the world. With decreased expertise and longer operative
Due to the increasing experience with laparoscopy, some specialised times, as well as an increase in robotic cases, the mentioned cost
centres have completed difficult reconstructive and ablative surgical advantage of laparoscopy decreases.
Bhayani also demonstrated that
procedures laparoscopically. Since extremely refined surgical skills and a robotic assistance – although encouraging – is a clear disadvantage in
high volume are required to complete such operations, the availability of terms of cost.
They further concluded that it was more effective to
such interventions is limited to few specialised centres. In particular, teach conventional laparoscopy. Bernie did not note any differences in
intacorporeal suturing challenges surgeons with limited laparoscopic the operative variables between robotics and straight laparoscopy.
Nevertheless, several expert centres have reported excellent Weise and Winfield made similar observations, with success rates
outcomes after laparoscopic pyeloplasty, paralleling those of open exceeding 97%.
Cost-effectiveness regarding endopyelotomy would be
surgery (see Table 2). Laparoscopic pyeloplasty is not a simple procedure, the best type of treatment for UPJO.
However, it has to be pointed out
requiring a significant learning curve and advanced laparoscopic skills. that cost is only one of a number of factors that are considered when
One of the largest series – of 100 laparoscopic pyeloplasties – by Jarrett deciding on an optimal course of treatment. Continuing evolution in the
revealed that the laparoscopic approach is technically challenging and a field and extended application in radical prostatectomy will further
lengthy procedure due to the high proficiency required for suturing.
The decrease current costs. Therefore, robotic devices are likely to be available
introduction of robotics addressed some of these limitations.
Even in an increasing number of centres.
though the application of robotic assistance in laparoscopy offers unique
advantages and durable long-term success, some disadvantages are Conclusions
present. Haptic feedback is lacking, requiring the surgeon to rely on visual Regarding our extended experience with robotic pyeloplasty and
impressions. Therefore, focusing on anatomical landmarks is the key to a currently available data, this approach turned out to be safe and feasible
successful operation. Additionally, the currently available devices are with many advantages for the patient. Moreover, this technique is highly
bulky, which may sometimes result in collisions requiring frequent effective with durable long-term success rates similar to open surgery.
realignments of the robotic arms. Furthermore, active communication There is a short learning curve, allowing this technique to be easily
between the surgeon – being away from the table – and the assistant is adopted by motivated surgeons and not only by those with extensive
a key feature streamlining the operation. Finally, the cost of the robot laparoscopic experience. Therefore, this procedure, which was once
remains considerable: an initial investment of US$1 million and limited to few specialised centres, may become more widespread. The
subsequent costs of US$80,000 a year, which may limit the availability of adoption of robotic technology will only hasten this process.
Up to now, studies comparing standard Unfortunately, the present costs may limit the universal use of robotic
laparoscopic pyeloplasty with the robotic approach remain contradictory. pyeloplasty in mainstream practice. However, due to the outstanding
Gettman demonstrated a 1.7 times longer operative time whereas Link safety and reproducibility, we have adopted da Vinci-assisted
reported shorter times for standard laparoscopy.
They also noted a laparoscopic pyeloplasty to treat primary and secondary UPJO. ■
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