Urological Surgery
Regarding the lymph-node yield, an estimated 30 cases were needed to obtain a lymph-node count of 20, and statistical analysis showed that the average lymph-node yield increased by 4.5 nodes for every 10 patients. Furthermore, it could be shown that approximately 30 cases were needed to reach a PSM of less than 5%. All in all, the authors concluded that 30 cases are needed to gain proficiency in performing robotic radical cystectomy.38
These results show clear
comparability to survival rates from open cystectomy and support the conclusion that robot-assisted radical cystectomy does not comprise cancer control, but long-term results are still needed to validate current literature.
Another crucial element during radical cystectomy is the extension of pelvic lymph-node dissection (PLND). Current literature debates the number of lymph nodes that should be retrieved during PLND. Initial data showed an improved survival rate when >11 lymph nodes were removed in lymph-node-positive patients.39
Other data showed
Abol-Enein et al. suggest that a cut-off number of 20 nodes was essential to determine the quality of PLND.41 other hand, Herr and colleagues36
an improved disease-specific survival rate of 65% when ≥16 lymph nodes were retrieved compared with 51% when
On the recommend the removal of just
10–14 lymph nodes as a standard procedure during PLND. PLND is one of the most technically demanding steps during radical cystectomy whether it is performed with a robotic aid or not. Special care must be given to avoid vascular or nerve injury. Studies have questioned the applicability of robotic surgery when it comes to PLND.42
For example, Wiklund and colleagues stated that laparoscopic lymphadenectomy is technically demanding and requires prolonged operation times.43
The majority of the published
data suggest that fewer nodes are removed laparoscopically than with the conventional open approach. These findings clearly question the laparoscopic approach from an oncological point of view. However, other data suggest that the robotic approach is not inferior to the open approach in PLND.44
Recently, Richards et al.45
The authors concluded that robot-assisted PLND is feasible and leads to similar results to the current gold standard, the open procedure.
published their initial experience with robot-assisted cystectomies. They compared 35 patients undergoing robotic surgery with 35 patients who underwent conventional open radical cystectomy. No significant difference between the open and robotic group was seen with regard to patient characteristics, tumour stage and node status (29% node-positive in each group). The reported total lymph node yield was similar in both groups with 15 nodes (interquartile range [IQR] 11–22) in the open group and 16 (IQR 11–24) in the robotic group. Positive margins were reported in three patients in the open group and only one patient had positive margins after robotic surgery.45
the biggest differences is the limited working space in children. The usual port distance of 8–10cm used in adult robotic surgery cannot be implemented in children because of their body size.47
All
manipulations of the ports should be performed under visual control because of an increased risk of visceral injury due to the small working space. One of the problems experienced initially was the size of the instruments of the da Vinci platform. Therefore, special paediatric instruments with a 5mm diameter instead of the adult 8mm diameter were designed and produced. The major difference between the paediatric 5mm instruments and their adult counterparts is that paediatric ones require a longer linear distance to facilitate full angulation. In other words, the 5mm instruments protrude further through the robotic cannula.48
Ureteropelvic junction obstruction is the most common cause for the development of infantile hydronephrosis.49
In the past, the open
conventional surgical approach was the gold standard for treatment, but the rise of laparoscopic and recently robot-assisted surgery has led to some significant changes in paediatric surgery. As already mentioned, the most significant advantages of robotic surgery are shortened hospitalisation, less post-operative pain and better cosmetic outcome without having any negative effects on the efficiency of the operation. Current studies are focusing on the safety, applicability and success rates of robot-assisted pyeloplasties.
In a recent study Gupta et al.50 demonstrated that robot-assisted
laparoscopic pyeloplasty is a safe and successful operative method for the treatment of ureteropelvic junction obstruction. The reported operation time was similar to that of the open approach, the learning curve was short and the post-operative course resulted in no major complications. All of these features of the robotic approach resulted in a significantly shortened hospitalisation time.
Interesting data proving the efficacy of robot-assisted pyeloplasty come from Freilich et al.51
This group of authors tried to investigate
the satisfaction of the parents of children who underwent robot-assisted pyeloplasty. For this reason all of the parents were interrogated with a validated questionnaire. In total, 127 children and their parents were included in the study: 79 children underwent conventional open surgery and 48 children underwent robotic pyeloplasty. The response rate to the questionnaire was 70%. The results of the questionnaire clearly showed that parent satisfaction with the post-operative outcome was significantly higher in the group who underwent the robotic procedure. The authors concluded that the worse outcome with the open approach was mainly to do with diminished self-esteem in children after open surgery due to scars, scar size, longer follow-up regime and delayed pain course.
Although the applicability of the robotic approach for PLND is still being debated, there is no doubt about the importance of a meticulous lymph-node dissection during radical cystectomy. It has been shown that node positivity is a significant and independent prognostic factor. Therefore, it has to be stated very clearly that adequate PLND has a direct effect on the survival of patients.
Robotic Surgery in Paediatric Urology The first robot-assisted surgery was performed in 2001 by Meininger et al. when they undertook a robotic assisted fundoplication.46 Paediatric robotic surgery is similar to that in adults, but one of
72
Robotic assisted surgery is even finding its way into the field of operative management of megaureters. The current literature is still scarce, but the results of available studies seem very promising.51,52
One of the greatest limitations of the use of the robot is the associated expense. By referring to expenses one has to think not only about the actual costs and maintainence expenditures, but also about the manpower necessary to use the robot properly. Yee et al.53 compared the average cost of robotic pyeloplasty with that of conventional open pyeloplasty and discovered that the robotic procedure costs US$5,466 per patient versus US$2,410 per patient for the conventional open approach.
EUROPEAN UROLOGICAL REVIEW
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