Robot-assisted laparoscopic extravesical ureteral reimplant: A critical look at surgical outcomes

Comparison of Robot-assisted Laparoscopic Extravesical Ureteral Reimplantation for Primary Vesicoureteral Reflux in Infants Under One Year of Age and Older Children

PURPOSE

To assess the surgical outcomes of Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation (RALUR-EV) in infants under one year of age with primary vesicoureteral reflux (VUR) as compared to older children.

MATERIALS AND METHODS

A retrospective analysis was conducted on 48 children with VUR who underwent unilateral or bilateral RALUR-EV between June 2018 and December 2022. Patients were divided into two groups: Group A (25 infants under one year) and Group B (23 children over one year). Preoperative evaluations included voiding cystourethrogram (VCUG), diuretic renography, ultrasonography, magnetic resonance urography, and urodynamic studies. Standard follow-up was conducted postoperatively, and both the resolution of reflux and any complications were meticulously documented.

RESULTS

All procedures were completed using the Da Vinci Surgical System without conversion to open surgery or major intraoperative complications. Group A had significantly smaller bladder capacities compared to Group B (70 [60, 90] ml vs. 150 [90, 200] ml, P <0.001) and a higher proportion of refractory febrile UTIs preoperatively (88.00 % vs. 60.87 %, P = 0.030). No significant differences in Operation time, estimated blood loss, or postoperative complications were observed between the groups. The success rates of reflux resolution were 96.00 % in Group A and 95.65 % in Group B. The length of hospital stay was significantly shorter in Group A (5 [4, 6] days vs. 7 [6, 10] days, P = 0.001).

CONCLUSION

RALUR-EV for the treatment of VUR in infants under one year of age is safe and effective. Compared to older children, the procedure does not increase intraoperative risks, and postoperative outcomes are comparable.

Is Postoperative Voiding Cystourethrogram Routinely Indicated Following Robotic-assisted Laparoscopic Ureteral Reimplantation in Children: Time to Define the New Standards?

OBJECTIVE

To examine the need to routinely obtain voiding cystourethrogram (VCUG) to confirm vesicoureteral reflux (VUR) resolution following robotic-assisted laparoscopic ureteral reimplantation (RALUR) in children.

METHODS

A single-center, prospectively maintained database was reviewed for patients <18 years old who underwent RALUR for VUR. Patient charts were reviewed for baseline characteristics and surgical details. Patients were routinely followed up by renal bladder ultrasound at 6-8 weeks and VCUG at 3 months postoperatively. The primary endpoint was radiological success defined as the absence of VUR on postoperative VCUG. The secondary endpoints were clinical success, defined as the absence of postoperative febrile urinary tract infection, postoperative urinary retention, and reoperation for persistent VUR or RALUR complications.

RESULTS

Between 2018 and 2023, 42 children (48 refluxing ureters) underwent extravesical RALUR at the study institution at a mean age of 70.4 + 23.7 months. A majority of 81% were females, and 85.7% had associated bladder and bowel dysfunction. Six patients (14.3%) had bilateral RALUR. Of the ureters, 83.4%(40/48) had grade III or higher VUR, and 20.8%(10/48) had duplex kidneys. Postoperative VCUG was completed in 36(85.7%) patients. Radiological reflux resolution was confirmed in 87.5%(35/40) of ureters. The remaining five ureters had VUR downgrading to grade I or II; all remained asymptomatic, and none required reoperation. One patient required ureteral stenting for 6 weeks for an unidentified unilateral ureteral injury without long-term consequences. Postoperative urine retention requiring short-term catheterization occurred in three patients. The clinical success rate was 97.6%.

CONCLUSION

After bypassing the learning curve, VCUG is not routinely indicated following RALUR for VUR.

Robot-Assisted Extravesical Ureteral Reimplantation (REVUR) in Pediatric Patients: A New Standard of Treatment for Patients with VUR-A Narrative Review

Robot-assisted extravesical ureteral reimplantation (REVUR) was described for the first time in 2004. Since then, the surgical approach of vesicoureteral reflux (VUR) has changed dramatically. The benefits of this technique are great when compared to the laparoscopic or traditional open approaches. A literature search of PubMed was performed to identify articles covering any aspect of REVUR in the pediatric population. A total of 108 papers published over the period 2004-2024 were collected. Of these, 40 studies were considered valuable in terms of obtaining a complete overview of the REVUR technique. This review aimed to describe the current state of the art of REVUR and define it as the new standard technique for surgical management of selected patients with VUR.

Minimally Invasive versus Open Ureteral Reimplantation in Children: A Systematic Review and Meta-Analysis

PURPOSE

 We performed a systematic review and meta-analysis to compare the safety and efficacy of minimally invasive surgery (MIS) versus open ureteral reimplantation (OUR) in children.

METHODS

 Literature searches were conducted to identify studies that compared MIS (laparoscopic ureteral reimplantation or robot-assisted laparoscopic ureteral replantation) and OUR in children. Parameters such as operative time, blood loss, length of hospital stay, success rate, postoperative urinary tract infection (UTI), urinary retention, postoperative hematuria, wound infection, and overall postoperative complications were pooled and compared by meta-analysis.

RESULTS

 Among the 7,882 pediatric participants in the 14 studies, 852 received MIS, and 7,030 received OUR. When compared with the OUR, the MIS approach resulted in shorter hospital stays (I 2 = 99%, weighted mean difference [WMD] -2.82, 95% confidence interval [CI] -4.22 to -1.41; p < 0.001), less blood loss (I 2 = 100%, WMD -12.65, 95% CI -24.82 to -0.48; p = 0.04), and less wound infection (I 2 = 0%, odds ratio 0.23, 95% CI 0.06-0.78; p = 0.02). However, no significant difference was found in operative time and secondary outcomes such as postoperative UTI, urinary retention, postoperative hematuria, and overall postoperative complications.

CONCLUSION

 MIS is a safe, feasible, and effective surgical procedure in children when compared with OUR. Compared with OUR, MIS has a shorter hospital stay, less blood loss, and less wound infection. Furthermore, MIS is equivalent to OUR in terms of success rate and secondary outcomes such as postoperative UTI, urinary retention, postoperative hematuria, and overall postoperative complications. We conclude that MIS should be considered an acceptable option for pediatric ureteral reimplantation.

Robotic Pediatric Urologic Surgery-Clinical Anesthetic Considerations: A Comprehensive Review

Minimally invasive robotic approaches have become standard in many institutions over the last decade for various pediatric urological procedures. The anesthetic considerations for common laparoscopic and robotic-assisted surgeries are similar since both require the insufflation of CO2 to adequately visualize the operative area. However, few studies exist regarding anesthesia for robotic procedures in children. We hypothesized that pediatric patients undergoing robotic urologic surgeries would require specific anesthetic strategies, especially given the inherently longer durations of these procedures. This study aimed to evaluate anesthetic considerations, current robotic procedures, optimal patient positioning, and port placement for robotic-assisted surgery in pediatric patients. A comprehensive literature review of all published manuscripts from PubMed, EMBASE database, and Google Scholar was performed, focusing on robotic procedures involving pediatric patients, anesthesia for pediatric urology patients, and related topics from 1996 to 2023. Forty published manuscripts were identified and reviewed in depth. In pediatric cases, insufflation pressures and volumes are lower due to the laxity of the abdominal wall. However, the increase in intra-abdominal pressure and absorption of CO2 may result in disproportionate changes in cardiopulmonary function. Specific patient positioning for robotic approaches may further compound these physiological changes. Correct patient positioning is essential to facilitate surgery optimally and safely. Understanding the physiological changes that can occur during a pediatric patient's robotic urologic surgery allows for safer anesthesia management.

Effectiveness of various treatment modalities in children with vesicoureteral reflux grades II-IV: a systematic review and network meta-analysis

BACKGROUND

Vesicoureteral reflux (VUR) is one of the most common risk factors of urinary tract infection (UTI) among children. Various treatment modalities including antibiotic prophylaxis, surgical or endoscopic corrections and conservative treatment were used depending on the severity of VUR. The aim of this study is to compare the effectiveness of these treatment modalities in children with VUR grades II-IV by conducting a systematic review and network meta-analysis.

METHODS

A systematic search from different databases was performed from their earliest records to December 2022 without any language restriction. Only randomised controlled trials were included in this study. Effectiveness of treatment modalities was mainly compared by UTI. Other outcomes for renal scarring and resolution by renal units were also measured between treatments.

RESULTS

A total of 11 studies with 1447 children were included in this study. While comparing with antibiotic prophylaxis in network meta-analysis for UTI recurrence, surgical treatment probably lowers the rate of UTI recurrence (Log OR -0.26, 95% CI -0.54 to 0.02, high quality). However, endoscopic treatment (Log OR 0.2, 95% CI -1.41 to 1.81, high quality) and conservative treatment (Log OR 0.15, 95% CI -0.45 to 0.75, high quality) revealed probably inferior to antibiotic treatment.

CONCLUSION

Both pairwise and network meta-analytic results probably showed no difference between the treatments in terms of their impact on UTI recurrence, progression of previous renal scars, or formation of new renal scars in children with VUR grades II-IV. These findings may offer a better understanding of each treatment and evidence-based suggestions for the choice of treatment, which should be individualised and based on the patient's risk factors.

Current trends in 2021 in surgical management of vesico-ureteral reflux in pediatric patients: results of a multicenter international survey on 552 patients

BACKGROUND

The selection of best surgical approach for treatment of vesico-ureteral reflux (VUR) in the pediatric population remains debated. This study aimed to report the results of a multicenter survey about the current trends in surgical management of pediatric VUR.

METHODS

An online questionnaire-based survey was performed, with participation of six international institutions. All children (age <18 years) affected by primary III-V grade VUR, who were operated over the last 5 years, were included. The incidence of each VUR intervention, patients' demographics and outcomes were analyzed.

RESULTS

A total of 552 patients (331 girls), with a median age of 4.6 years (range 0.5-17.6), were included. Deflux^® injection (STING) was the most common technique (70.1%). The multicenter success rate after single treatment was significantly lower after STING (74.4%) compared with the other treatments (P=0.001). Persistent VUR rate was significantly higher after STING (10.8%) compared with the other treatments (P=0.03). Choosing endoscopy over surgery mean reducing Clavien Dindo grade 2 complications by 5% but increasing redo procedure rate by 7%. STING was the most cost-effective option.

CONCLUSIONS

This survey confirmed that the choice of the technique remains based on surgeon's preference. Deflux^® injection currently represents the first line therapy for primary VUR in children and the role of surgical ureteral reimplantation is significantly reduced. STING reported acceptable success rate, less postoperative complications and lower costs but higher failure and re-operation rates and related costs compared with the other surgical approaches. The adoption of laparoscopy and robotics over open reimplantation remains still limited.

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

PURPOSE

To describe a novel modification of technique to improve efficacy of robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) in infants.

MATERIALS AND METHODS

Between 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.

RESULTS

All 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.

CONCLUSION

Our 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.

The place of retroperitoneoscopic hemi-nephroureterectomy for duplex kidney in children; risk of damage to the remnant moiety and strategies to reduce the risk

OBJECTIVE

To analyse the outcomes of retroperitoneoscopic upper and lower moiety hemi-nephroureterectomy (HNU) and to assess the different variables that may have an impact on outcome; remnant moiety damage, morbidity and the need for secondary surgery.

METHODS

Prospectively recorded data of retroperitoneoscopic HNU's performed by a single surgeon from 2005 to 2018 were analysed. Patients were split into 2 groups according to moiety affected (UMHNU and LMHNU). Clinical presentation, underlying pathology, remnant moiety DRF on renal scintigraphy, and need for further surgery were recorded. Detailed operation notes were studied regards to renal vasculature, degree of dilatation, inflammatory changes and operative difficulties encountered. Renal loss was defined as remnant moiety DRF <10% post-operatively. Change in DRF was assessed regards to the moiety, pathology and age at surgery (<1 year, 1-2 years and ≥2 years). UMHNU group was further sub-divided into 3 subgroups: ureteroceles, ectopic ureters and 'other' pathology. Statistical analysis was performed using Fishers Exact test; findings were considered statistically significant at p < 0.05.

RESULTS

78 operations met the inclusion criteria on 75 patients (3 bilateral). There were no conversions to open, and 67% were performed as day-case procedures (53/78 patients). In 91.2% (71/78) patients the procedure was definitive in resolving pathology and symptoms. 7 patients needed further procedures after HNU, 5 for ureterocele/ureteric stump. Overall, there was remnant moiety renal loss in 5.1% (4/78) patients, all with UM surgery (3 ectopic ureters and 1 ureterocele). All 4 operations were recorded prospectively as 'difficult operations' due to grossly dilated UM ureter/pelvis measuring >2 cm in diameter. 2 patients had a thinned out lower moiety (LM) sitting on top of the UM renal pelvis like a pancake with all vessels stretched over this dilated pelvis/ureter causing difficulty in accurate identification. There was intra-operative concern about some damage to LM vessels in 3 patients. Age <1year was also related to increased renal loss (2/8 patients <1 year, 1/25 patients 1-2 years, 1/45 patients ≥2 years of age P = 0.005).

CONCLUSION

Retroperitoneoscopic LMHNU is a safe and definitive procedure with rapid recovery and minimal scarring. UMHNU has higher rates of remnant moiety loss due to more complex renal pathology, but remains a safe, successful operation on the majority of patients. Renal damage was also related to age <1year (p = 0.005) and re-operation risk after UMHNU correlated to the presence of ureterocele (p = 0.003).

Armamentarium to treat primary vesicoureteral reflux in children

Primary vesicoureteral reflux often spontaneously resolves in children. However, in select patients, untreated reflux can contribute to recurrent pyelonephritis leading to irreversible renal damage. Management is therefore based on a given child's likelihood of recurrent urinary tract infections and risk of subsequent renal parenchymal injury. Therapeutic options for urinary reflux are diverse, ranging from observation with or without continuous low-dose antibiotic prophylaxis to a variety of operative interventions.

Robot‑Assisted Laparoscopic Extra-Vesical Ureteral Reimplantation (Ralur/Revur) for Pediatric Vesicoureteral Reflux: A Systematic Review of Literature

This literature review aimed to assess the outcomes of robot-assisted laparoscopic extra-vesical ureteral reimplantation (RALUR/REVUR) in standard, complex and re-operative cases. Twenty-two studies (period 2008-2019) containing 1362 children receiving RALUR/REVUR, were included. Unilateral repair was faster compared to bilateral (P = .0000). The overall patient success rate was 92%. The mean post-operative complications rate was 10.7%. The mean re-operations rate was 3.9%. The available data show that RALUR/REVUR can be a first line surgical approach for pediatric vesicoureteral reflux at most centers with the caveat that learning curves for the surgeons are expected as with most new surgical procedures.

Parental preferences for vesicoureteral reflux treatment: Profile case best-worst scaling

INTRODUCTION

Vesicoureteral reflux is a common pediatric urologic condition that often has several reasonable treatment options depending on condition severity. In order to choose the best treatment for their child, parents are expected to make judgements that weigh attributes such as treatment cost, effectiveness, and complication rate. Prior research has shown that factors such as treating hospital and surgeon also influence patient treatment choice.

OBJECTIVES

This study evaluates parental preferences for reflux treatment using profile case best-worst scaling, an emerging technique in both urologic and health care preference estimation. The study also uses latent class analysis (LCA) to identify parental sub-classes with different preferences.

STUDY DESIGN

Data were collected from a community sample of parents via a multimedia best-worst scaling survey instrument published to Amazon's Mechanical Turk online community. After extensive review of the literature, reflux attributes and attribute levels were selected to correspond with available treatments. The profile case best-worst scaling exercise elicited preferences for granular attributes of reflux treatments. Data were analyzed using multinomial logistic regression and class analysis to distinguish preference heterogeneity. Probability scaled values (PSVs) reflected the order of desirability of the attributes. Attribute preference importance was rescaled into dollar units for comparison as well.

RESULTS

We analyzed data for 248 respondents. The highest treatment effectiveness was more desirable than all other leveled treatment attributes (PSV 17.8, all p < 0.01) (Table). Low complication rate and doctor recommendation were amongst the other most desirable treatment attributes (PSV 11.3 and 9.0, respectively). Latent class analysis identified a class with more extreme preferences, for whom doctor recommendation and avoiding hospitalization were particularly desirable.

DISCUSSION

In this community-based sample, high treatment effectiveness and low complication rate were the most desirable treatment attributes to parents, though parents likely have heterogenous treatment preference structures. Shared parent-physician decision-making that incorporates parental preferences will likely allow more effective, targeted decision-making in the future.

Management of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years?

Vesicoureteral reflux (VUR) is associated with increased risks of urinary tract infection, renal scarring and reflux nephropathy. We review advancements over the last two decades in our understanding and management of VUR. Over time, the condition may resolve spontaneously but it can persist for many years and bladder/bowel dysfunction is often involved. Some factors that increase the likelihood of persistence (e.g., high grade) also increase the risk of renal scarring. Voiding cystourethrography (VCUG) is generally considered the definitive method for diagnosing VUR, and helpful in determining the need for treatment. However, this procedure causes distress and radiation exposure. Therefore, strategies to reduce clinicians' reliance upon VCUG (e.g., after a VUR treatment procedure) have been developed. There are several options for managing patients with VUR. Observation is suitable only for patients at low risk of renal injury. Antibiotic prophylaxis can reduce the incidence of UTIs, but drawbacks such as antibiotic resistance and incomplete adherence mean that this option is not viable for long-term use. Long-term studies of endoscopic injection have helped us understand factors influencing use and the effectiveness of this procedure. Ureteral reimplantation is still performed commonly, and robot-assisted laparoscopic methods are gaining popularity. Over the last 20 years, there has been a shift toward more conservative management of VUR with an individualized, risk-based approach. For continued treatment improvement, better identification of children at risk of renal scarring, robust evidence regarding the available interventions, and an improved VUR grading system are needed.

Utilization of Robot-assisted Surgery for the Treatment of Primary Obstructed Megaureters in Children

OBJECTIVE

To describe the technical aspects of robot assisted laparoscopic ureteral reimplantation (RALUR) for the management of primary obstructive megaureter (POM) and report initial outcomes, safety, and feasibility of the procedure.

METHODS

Using an IRB- approved robotic surgery registry, we performed a retrospective chart review of patients undergoing RALUR for POM between April 2009 and May 2019.

RESULTS

A total of 18 patients underwent RALUR using a modified Lich-Gregoir technique for management of POM and 7 (38.9%) of these underwent intracorporeal ureteral tapering at the time of surgery. At median follow up of 27.5 (IQR 11-50) months, no patient required reoperation for recurrent obstruction and all patients had improvement in hydronephrosis postoperatively. 30-day complications were low with 1 Grade I, 2 Grade II and 1 Grade III Clavien-Dindo complication. The most common issue postoperatively was febrile urinary tract infection, occurring in 6 patients (33.3%), at an average of 3.2 months after surgery. Increased operative time was the only significant difference between the tapered verses nontapered group.

CONCLUSION

We present the largest series of RALUR for POM to date. Based upon our initial experience with this technique we believe it is technically feasible and reproducible with good outcomes and low complication rates. Future studies are needed to track long-term outcomes and better understand indications for and the utility of ureteral tapering as well as how to minimize febrile UTIs postoperatively. Additional follow up is needed to determine the efficacy of RALUR as compared to open ureteral reimplantation for POM.

Duplex systems: Top-down or bottom-up approach?

INTRODUCTION

Duplex systems can be complicated by reflux, ureterocele, obstruction (most commonly PUJ in a lower moiety) and wetting secondary to an ectopic ureteric insertion in girls. The decision making algorithm for selection of surgical approach is complex and there is no consensus. The authors described the outcomes following an upper urinary tract approach in 2011(1) and now compare these results in a similar group of patients managed using a lower approach.

OBJECTIVES

To assess whether a top-down or bottom-up approach results in different likelihoods for further surgery.

STUDY DESIGN

A prospectively database was maintained for consecutive patients undergoing surgery for duplex systems by a single surgeon between 2003 and 2015. Patients were classified into 2 groups; Group 1 initial intention for upper urinary tract approach (heminephroureterectomy-HN) or Group 2 lower urinary tract approach (bladder reconstructive surgery-BRS). The requirement for further surgery was recorded-endoscopic incision (EI), bladder reconstructive surgery (BRS), endoscopic correction of reflux (ECR), heminephroureterectomy (HN). Indications for initial and subsequent surgery included urinary tract infection, VUJ obstruction and incontinence. Endoscopic incision was not performed for patients with an asymptomatic ureterocele. Statistical analysis consisted of Fisher's exact test with a 2 tail p value < 0.05 being statistically significant.

RESULTS

79 patients underwent surgery for duplex systems. 39 patients had HN initially (Group 1) and 40 patients had BRS initially (Group 2). Further surgery was performed in 21% of patients from Group 1 (8 BRS) vs 5% of patients from Group 2 (1 redo BRS, 1 ECR). Significantly less additional surgical procedures were performed after BRS compared to HN (p = 0.048). The presence of both reflux and ureterocele increases the chances of further surgery in those patients who had HN initially compared to BRS (p = 0.01). No patients developed urinary retention or required intermittent catheterisation to improve bladder emptying.

CONCLUSIONS

Bladder reconstructive surgery (BRS) reduces the requirement for further surgery compared to heminephroureterectomy (HN) in symptomatic patients with a duplex kidney and either dilating vesicoureteric reflux or ureterocele.

Robotic Ureteral Reimplantation

Minimally invasive techniques have gained popularity in pediatric surgery. Among these, is the robotic approach for ureteral reimplantation in children with vesico-ureteral reflux. We describe main indications of this surgery, our surgical technique as well as trouble shooting of anatomical variants and the post-operative management. We also provide a description of other techniques described in the literature and a brief review of outcomes of published series.

Parental Preferences for Vesicoureteral Reflux Treatment: A Crowd-sourced, Best-worst Scaling Study

OBJECTIVE

To quantitatively evaluate parental preferences for the various treatments for vesicoureteral reflux using crowd-sourced best-worst scaling, a novel technique in urologic preference estimation.

METHODS

Preference data were collected from a community sample of parents via 2 best-worst scaling survey instruments published to Amazon's Mechanical Turk online community. Attributes and attribute levels were selected following extensive review of the reflux literature. Respondents completed an object case best-worst scaling exercise to prioritize general aspects of reflux treatments and multiprofile case best-worst scaling to elicit their preferences for the specific differences in reflux treatments. Data were analyzed using multinomial logistic regression. Results from the object-case provided probability scaled values (PSV) that reflected the order of importance of attributes.

RESULTS

We analyzed data for 248 and 228 respondents for object and multiprofile case BWS, respectively. When prioritizing general aspects of reflux treatment, effectiveness (PSV = 20.37), risk of future urinary tract infection (PSV = 14.85), and complication rate (PSV = 14.55) were most important to parents. Societal cost (PSV = 1.41), length of hospitalization (PSV = 1.09), and cosmesis (PSV = 0.91) were least important. Parents perceived no difference in preference for the cosmetic outcome of open vs minimally invasive surgery (P = .791). Bundling attribute preference weights, parents in our study would choose open surgery 74.9% of the time.

CONCLUSION

High treatment effectiveness was the most important and preferred attribute to parents. Alternatively, cost and cosmesis were among the least important. Our findings serve to inform shared parent-physician decision-making for vesicoureteral reflux.

Robotic Urologic Surgery in Infants: Results and Complications

Over the last 30 years, robotic surgery has evolved into the preferred surgical approach for many operative cases. Robotics has been associated with lower pain scales, shorter hospitalizations, and improved cosmesis (1, 2). However, its acceptance in pediatrics have been hampered by longer operative times, smaller working space, and limited fine surgical instruments. Many find these challenges even more pronounced when performing robotic surgery in infants (i.e., children <1 year old). Although the data in infants is less robust, many studies have shown benefits similar to the adult population. Specifically, multiple reports of robotic surgery in infants have shown lower postoperative analgesic use. Additionally, hospital stays are shorter, which may lead to quicker return to work for parents and guardians. Multiple reports have shown low complication rates of robotic surgery in infants. When complications have occurred, they are usually Clavien Grade 1 and 2, with occasional grade 3. Often the complications are not from the robotic technique, but are linked to other factors such as the ureteral stents (3, 4). Most importantly, the success rates of surgery are comparable to open surgery. This chapter will review indications for the most common urologic robotic surgeries performed in infants. Also, we will review reported results and complications of robotic surgery in children, with specific attention to the infant population. However, data focused only on infants is limited. Many studies have some infant patients, but their results are often mixed with all pediatric patients.

The Robot-Assisted Extravesical Anti-reflux Surgery: How We Overcame the Learning Curve

Management of vesicoureteral reflux (VUR) has evolved over the past several decades, with a trend toward a decrease in surgical management. In spite of this, ureteral reimplantation remains a commonly performed procedure by pediatric urologists in selected cases. Although the basic tenets of the ureteral reimplant procedure remain the same, the extra- vs. intravesical approach, and the traditional open vs. minimally invasive approach remain the primary options to correct reflux. Considering the advantages conferred by the robotic surgery platform, many leading centers have preferentially adopted robot-assisted laparoscopic extravesical anti-reflux surgery, or in common surgical parlance, the robot-assisted laparoscopic ureteral reimplantation (RALUR), over pure laparoscopic or open approaches. Predicated on our experience of performing over 170 cases of RALUR, we have made technical modifications which we posit reduce the morbidity of the procedure while offering acceptable outcomes. This review highlights the evolution and establishment of RALUR as a standardization of care in the surgical management of VUR at our institution. In particular, we emphasize the technical nuances and specific challenges encountered through the learning curve in hopes of facilitating this process for others.

Robotic Ureteral Reconstruction in the Pediatric Population

Robot-assisted laparoscopic (RAL) surgery is a safe, minimally invasive technique that has become more widely used in pediatric urology over recent decades. With several advantages over standard laparoscopy, robotic surgery is particularly well-suited to reconstructive surgery involving delicate structures like the ureter. A robotic approach provides excellent access to and visualization of the ureter at all levels. Common applications include upper ureteral reconstruction (e.g., pyeloplasty, ureteropelvic junction polypectomy, ureterocalicostomy, and high uretero-ureterostomy in duplex systems), mid-ureteral reconstruction (e.g., mid uretero-ureterostomy for stricture or polyp), and lower ureteral reconstruction (e.g., ureteral reimplantation and lower ureter-ureterostomy in duplex systems). Herein, we describe each of these robotic procedures in detail.

Robotic surgery in pediatric urology: Current status

Robot-assisted laparoscopic surgery (RALS) has been increasingly embraced in the fields of adult and pediatric urology, especially in North America and Europe. The advantages of a stable magnified 3-D view, tremor filtering, and motion scaling allow for precise intracorporeal exposure and suturing. Because most surgeries are performed as reconstructive rather than excision procedures, the robotic platform is particularly feasible for the field of pediatric urology. In this review, we summarize the recent viewpoints on RALS, such as pyeloplasty, ureteral reimplantation, bladder neck reconstruction, bladder neck sling, appendicovesicostomy, bladder diverticulectomy, and treatments for ureterocele or ectopic ureters, and we also critically summarize the current status of the literature. Based on our initial experience, RALS is technically feasible for pediatric patients and may be achieved with comparable surgical outcomes. RALS is also associated with reduced morbidity compared to open surgery to conventional laparoscopic surgery. This evolution will offer an alternative in the treatment pediatric patients, along with improved care and patient quality of life. Further large case series and randomized controlled trials that investigate the robotic platform's technological improvements will help to expand indications of RALS in the field of pediatric urology.

Vesicoscopic cross-trigonal ureteral reimplantation: High success rate for elimination of primary reflux

INTRODUCTION

Open ureteral reimplantation (UR) is the gold standard for the surgical management of vesicoureteral reflux (VUR). There have been increasing reports on robot-assisted UR, but this approach remains controversial due to reports suggesting increased complications and reduced success compared with open repair. This study presented extensive experience with vesicoscopic ureteral reimplantation (VR) for primary reflux. In this procedure, cross-trigonal reimplantation was performed in a manner analogous to open repair under carbon dioxide 'pneumovesicum'.

OBJECTIVE

To review outcomes of vesicoscopic cross-trigonal ureteral reimplantation and compare them with other minimally invasive approaches for the correction of reflux.

STUDY DESIGN

All patients who underwent VR at the current institution were retrospectively reviewed. The following were recorded for each patient: age, sex, grade of reflux, operative time, outcome, and complications.

RESULTS

The series consisted of 182 consecutive patients who underwent VR. There were 165 girls and 17 boys. Mean age was 7.03 years (range 16 months-38.2 years). Fifteen had failed prior injection therapy. Of the 182 patients, 135 underwent bilateral repairs and 47 unilateral. Mean operative time for bilateral repairs was 197 (112-284) minutes and 169 (99-288) for unilateral. Major complications included two ureteral obstructions: one resolved with stent placement and the other underwent re-operative reimplantation. Postoperative voiding cystourethrogram (VCUG) was obtained in 100 patients and was normal in 93 (93%). Four of these failures occurred in the first 30 patients. Of the last 49 patients tested, 48 were normal, suggesting a 98% effective success rate after the learning curve.

DISCUSSION

Vesicoscopic ureteral reimplantation is an approach that completely recreates all aspects of open cross-trigonal repair. Complications were uncommon and success rates were very high in the current study.

CONCLUSIONS

Vesicoscopic ureteral reimplantation is a minimally invasive procedure for the definitive repair of primary reflux. After the learning curve at the current institution, success rates were found to be equivalent to open repair and were higher than published reports of robot-assisted procedures.

Robot-assisted laparoscopic versus open ureteral reimplantation for pediatric vesicoureteral reflux: a systematic review and meta-analysis

OBJECTIVE

To compare the efficacy and safety of robot-assisted laparoscopic ureteral reimplantation (RALUR) and open ureteral reimplantation (OUR) in treating primary pediatric vesicoureteral reflux (VUR) based on published literature.

METHODS

A comprehensive literature search of PubMed, Embase, Cochrane Library, CBM, CNKI and VIP databases was conducted to identify studies comparing the outcomes of RALUR with OUR for treating primary pediatric VUR. The last search was in January 2017. Summarized mean differences (MDs) or odds ratios (ORs) with 95% confidence intervals (CIs) were used to assess the differences in outcomes between RALUR and OUR.

RESULTS

A total of six studies containing 7122 children with primary VUR were included in this analysis. Significantly longer operation time was needed for RALUR than OUR (MD 66.69 min, 95% CI 41.71-91.67, P < 0.00001), while the RALUR group had significantly fewer days of hospital stay (MD - 17.80 h, 95% CI - 21.18 to - 14.42, P < 0.00001) and postoperative Foley placement (MD - 0.32 days, 95% CI - 0.57 to - 0.07, P = 0.01). No significant differences were found in estimated blood loss during operation, success rate, complications, and postoperative analgesia usage between the two groups. In subgroup analyses, a significantly higher rate of short-term postoperative complications in RALUR was found compared with OUR (OR 3.17, 95% CI 1.72-5.85, P = 0.0002).

CONCLUSIONS

Our study indicates that compared with OUR, RALUR is also an effective surgical approach for primary pediatric VUR and could help patients return to society more quickly; however, short-term postoperative complications of RALUR should be considered cautiously.

Minimally Invasive Management for Vesicoureteral Reflux in Infants and Young Children

Minimally invasive ureteral reimplantation is an attractive and useful tool in the armamentarium for the management of complicated vesicoureteral reflux (VUR). Subureteric dextranomer/hyaluronic acid injection, laparoscopic extravesical ureteric reimplantation and pneumovesicoscopic intravesical ureteral reimplantation with or without robotic assistance are established minimally invasive approaches to management of VUR. The high cost and the limited availability of robotics have restricted accessibility to these approaches. Laparoscopic and/or robotic ureteral reimplantation continues to evolve and will have a significant bearing on the management of complicated VUR in infants and young children.

Contemporary Management of Vesicoureteral Reflux

CONTEXT

Vesicoureteral reflux (VUR) remains the most interesting topic of pediatric urology due to the dynamic nature of recent controversial publications. Starting from the need for a diagnosis to the necessity and effectiveness of treatment in preventing scars, VUR remains in the mist. Although recent strong evidence helped as fog lights in this blurriness, more data are required for achieving crystal clearance. This article aims to summarize and discuss the current state of the evidence regarding VUR management.

OBJECTIVE

To provide a comprehensive synthesis of the main evidence in the literature on the current and contemporary management of VUR in children; to discuss conservative management with continuous antibiotic prophylaxis (CAP), especially its effectiveness and safety; and to review the current evidence regarding contemporary surgical techniques.

EVIDENCE ACQUISITION

We conducted a nonsystematic review of the literature using the recent guidelines and PubMed database regarding surveillance, CAP, endoscopic, open, laparoscopic, and robot-assisted ureteral surgical treatment.

EVIDENCE SYNTHESIS

Despite the striking results of previous studies revealing the ineffectiveness of CAP, more recent studies and their two fresh meta-analyses revealed a positive role for CAP in the contemporary management of VUR. One of the most interesting findings is the redundant rising of endoscopic correction and its final settlement to real indicated cases. Patient individualization in the contemporary management of VUR seems to be the keyword. The evidence in the literature showed a safe and effective use of laparoscopic and robot-assisted laparoscopic reimplantations.

CONCLUSIONS

The goal of VUR treatment is to prevent the occurrence of febrile urinary tract infections and formation of scars in the renal parenchyma. The approach should be risk adapted and individualized according to current knowledge. Individual risk is influenced by the presentation age, sex, history of pyelonephritis and renal damage, grade of reflux, bladder bowel dysfunction, and circumcision status.

PATIENT SUMMARY

Vesicoureteral reflux is a nonphysiological reflux of urine from the bladder through the ureters to the kidney. Treatment depends on the presentation of the vesicoureteral reflux (VUR). Therapeutic options range from watchful waiting to open surgery. This article aims to summarize and discuss the current state of the evidence regarding VUR management.

Laparoscopic vesico-ureteral reimplantation with Lich-Gregoir approach in children: medium term results of 159 renal units in 117 children

PURPOSE

Vesico-ureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. Surgery is an important part of its management. Laparoscopic ureteric reimplantation using the Lich-Gregoir technique is an option for VUR. The aim of this study is to assess short- and medium-term outcomes of this approach.

MATERIALS AND METHODS

This is a retrospective study including all children with VUR treated by laparoscopic extravesical ureteral reimplantation with the Lich-Gregoir technique in University Hospital of Saint-Etienne from August 2007 to May 2016. Surgery was performed after the age of 12 months in cases with repeated urinary tract infection (UTI) and a deterioration of renal function. All patients were followed-up post operatively.

RESULTS

117 children (92 girls, 25 boys) representing 159 renal units were included. The mean age at surgery was 47.1 months (±32.7 months). The mean follow-up was 59.3 months (±31 months). The resolution rate for VUR in terms of no febrile urinary UTIs was 98.3%. The mean operative time was 96 min (±37.7 min) for unilateral procedures and 128 min (±46.1 min) for bilateral procedures. The mean hospital stay was 25.3 h (±6.3 h). There was no difference between males and females regarding age, weight, renal function or follow-up duration.

CONCLUSIONS

Laparoscopic reimplantation with Lich-Gregoir technique is an efficient, quick and safe technique for the management of VUR. The success rate is comparable to open techniques with the advantages of laparoscopic approach; this can potentially be performed as a Day Case procedure.

Lessons learned over a decade of pediatric robotic ureteral reimplantation

The da Vinci robotic system has improved surgeon dexterity, ergonomics, and visualization to allow for a minimally invasive option for complex reconstructive procedures in children. Over the past decade, robot-assisted laparoscopic ureteral reimplantation (RALUR) has become a viable minimally invasive surgical option for pediatric vesicoureteral reflux (VUR). However, higher-than-expected complication rates and suboptimal reflux resolution rates at some centers have also been reported. The heterogeneity of surgical outcomes may arise from the inherent and underestimated complexity of the RALUR procedure that may justify its reclassification as a complex reconstructive procedure and especially for robotic surgeons early in their learning curve. Currently, no consensus exists on the role of RALUR for the surgical management of VUR. High success rates and low major complication rates are the expected norm for the current gold standard surgical option of open ureteral reimplantation. Similar to how robot-assisted laparoscopic surgery has gradually replaced open surgery as the most utilized option for prostatectomy in prostate cancer patients, RALUR may become a higher utilized surgical option in children with VUR if the adoption of standardized surgical techniques that have been associated with optimal outcomes can be adopted during the second decade of RALUR. A future standard of RALUR for children with VUR whose parents seek a minimally invasive surgical option can arise if widespread achievement of high success rates and low major complication rates can be obtained, similar to the replacement of open surgery with robot-assisted laparoscopic radical prostectomy as the new strandard for men with prostate cancer.