Schwenter_edit.qxp 27/7/07 04:11 Page 60
Urological Surgery
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.
36
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.
37
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.
38
skills.
4,7,8
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%.
39
Cost-effectiveness regarding endopyelotomy would be
surgery (see Table 2). Laparoscopic pyeloplasty is not a simple procedure, the best type of treatment for UPJO.
40
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.
7
The decrease current costs. Therefore, robotic devices are likely to be available
introduction of robotics addressed some of these limitations.
11
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.
robotic technology.
36
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.
10,36
They also noted a laparoscopic pyeloplasty to treat primary and secondary UPJO. ■
1. Tan BJ, Smith AD, Ureteropelvic junction obstruction repair: 12. Kaul S, Laungani R, Sarle R, et al., Da Vinci-assisted robotic obstruction, Curr Opin Urol, 2006;16:291–4.
when, how, what?, Curr Opin Urol, 2004;14(2):55–9. partial nephrectomy: technique and results at a mean of 15 24. Olsen LH, Jorgensen TM, Computer assisted pyeloplasty in
2. Inagaki T, Rha KH, Ono AM, et al., Laparoscopic pyelplasty: months of follow-up, Eur Urol, 2007;51(1):186–92. children: the retroperitoneal approach, J Urol, 2004;171
current status, BJU Int, 2005;95(2):102–5. 13. Partin AW, Adams JB, Moore RG, Kavoussi LR, Complete robot- (6 Pt 2):2629–31.
3. Van Cangh PJ, Wilmart JF, Opsomer RJ, et al., Long-term assisted laparoscopic urologic surgery: a preliminary report, 25. Atug F, Woods M, Burgess SV, et al., Robot assisted
results and late recurrence after endoureteropyelotomy: a J Am Coll Surg, 1995;181(6):552–7. laparoscopic pyeloplasty in children, J Urol, 2005;174(4 Pt 1):
critical analysis of prognostic factors, J Urol, 1994;151(4): 14. Sung GT, Gill IS, Hsu TH, Robotic-assisted laparoscopic 1440–42.
934–7. pyeloplasty: a pilot study, Urology, 1999;53(6):1099–1103. 26. Kutikow A, Nguyen M, Guzzo T, et al., Robot-assisted
4. Schuessler WW, Grune MT, Tecuanhuey LV, Preminger GM, 15. Sung GT, Gill IS, Robotic laparoscopic surgery: a comparison of pyeloplasty in the infant-Lessons learned, J Urol, 2006;176:
Laparoscopic dismembered pyeloplasty, J Urol, 1993;150(6): the DA Vinci and Zeus Systems, Urology, 2001;58(6):893–8. 2237–40.
1795–9. 16. Peschel R, Neururer R, Bartsch G, Gettman MT, Robotic 27. Lee RS, Retik AB, Borer JG, Peters CA, Pediatric robot assisted
5. Jarrett TW, Chan DY, Charambura TC, et al., Laparoscopic pyeloplasty: technique and results, Urol Clin N Am, laparoscopic dismembered pyeloplasty: comparison with a
pyeloplasty: the first 100 cases, J Urol, 2002;167(3):1253–6. 2004;31:737–41. cohort of open surgery, J Urol, 2006;175:683–7.
6. Zhang X, Li HZ, Ma X, Zheng T, et al., Retrospective 17. Palese MA, Munver R, Phillips CK, et al., Robot-assisted 28. Yee DS, Shanberg AM, Duel BP, et al., Initial comparison of
comparison of retroperitoneal laparoscopic versus open laparoscopic dismembered pyeloplasty, JSLS, 2005;9:252–7. robotic-assisted laparoscopic versus open pyeloplasty in
dismembered pyeloplasty for ureteropelvic junction obstruction, 18. Chammas MF, Hubert J, Patel VR, Robotically assisted children, Urology, 2006;67(3):599–60.
J Urol, 2006;176(3):1077–80. laparoscopic pyeloplasty: a transatlantic comparison of 29. Link RE, Bhayani SB, Kavoussi LR, A prospective comparison of
7. Tan BJ, Rastinehad AR, Marcovich R, et al., Trends in techniques and outcomes, BJU Int, 2007;99(5):1113–7. robotic and laparoscopic pyeloplasty, Ann Surg, 2006;243:
ureteropelvic junction obstruction management among 19. Mendez-Torres F, Woods M, Thomas R, Technical modifications 486–91.
urologists in the United States, J Urol, 2005;65(2):260–64. for robot-assisted laparoscopic pyeloplasty, J Endourol, 30. Bhayani SB, Link RE, Varkarakis JM, Kavoussi LR, Complete
8. Gettman MT, Peschel R, Neururer R, Bartsch G, A comparison 2005;19(3):393–6. daVinci versus laparoscopic pyeloplasty: cost analysis,
of laparoscopic pyeloplasty performed with the daVinci robotic 20. Mandhani A, Goel S, Bandhari M, Is antegrade stenting J Endourol, 2005;19(3):237–2.
system versus standard laparoscopic techniques: initial clinical superior to retrograde stenting in laparoscopic pyeloplasty?, 31. Bernie JE, Venkatesh R, Brown J, et al., Comparison of
results, Eur Urol, 2002;42(5):453–7. J Urol, 2004;171(4):1440–42. laparoscopic pyeloplasty with and without robotic assistance,
9. Duchene DA, Moinzadeh A, Gill IS, Clayman RV, et al., Survey 21. Chammas Jr M, Feuillu B, Coissard A, Hubert J, Laparoscopic JSLS, 2005;9:258–61.
of residency training in laparoscopic and robotic surgery, J Urol, robotic-assisted management of pelvi-ureteric junction 32. Weise ES, Winfield HN, Robotic computer-assisted pyeloplasty
2006;176(5):2158–66. obstruction in patients with horseshoe kidneys: technique and versus conventional laparoscopic pyeloplasty, J Endourol,
10. Menon M, Shrivastava A, Tewari A, Laparoscopic radical 1-year follow-up, BJU Int, 2006;97:579–83. 2006;20(10):813–9.
prostatectomy: conventional and robotic, Urology, 22. Sundaram CP, Grubb III RL, Rehman J, et al., Laparoscopic 33. Gettman MT, Lotan Y, Roerhborn CG, et al., Cost-effective
2005;66(Suppl. 5):101–4. pyeloplasty for secondary ureteropelvic junction obstruction, treatment for ureteropelvic junction obstruction: a decision tree
11. Palese MA, Munver R, Phillips CK, et al., Robot-assisted J Urol, 2003;169(6):2037–40. analysis, J Urol, 2003;169(1):228–32.
laparoscopic dismembered pyeloplasty, JSLS, 2005;9:252–7. 23. Lee RS, Borer JG, Robotic surgery for ureteropelvic junction
60 EUROPEAN GENITO-URINARY DISEASE 2007
Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76  |  Page 77  |  Page 78  |  Page 79  |  Page 80  |  Page 81  |  Page 82  |  Page 83  |  Page 84  |  Page 85  |  Page 86  |  Page 87  |  Page 88  |  Page 89  |  Page 90  |  Page 91  |  Page 92  |  Page 93  |  Page 94  |  Page 95  |  Page 96  |  Page 97  |  Page 98  |  Page 99  |  Page 100