Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation for Primary Vesicoureteral Reflux in Children

A systematic review and meta-analysis of conventional laparoscopic versus robot-assisted laparoscopic pyeloplasty in infants

OBJECTIVE

While there are several reports confirming the safety and efficacy of laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP) in children there have been none comparing LP and RALP specifically in infants. In this meta-analysis, we have compared the outcomes of LP and RALP in infants.

METHODS

Pubmed (Medline), Publon, Index Medicus and Embase were searched using the search terms: pyeloplasty (laparoscopic OR robot-assisted) AND (infant), to identify all papers pertaining to LP and RALP. Systematic review was performed to identify information regarding number of patients/renal units, age, body weight, operating time, hospital stay, success and complications. Meta-analysis of heterogeneity was reported with I2statistics. Once heterogeneity was found low, the pooled outcomes were compared with student's t test and Fishers exact test, wherever appropriate.

RESULTS

After screening a total of 267 articles, 18 articles were included (10 articles on LP, 7 on RALP, 1 reporting both), comprising 323 renal units for LP and 173 renal units for RALP. With low heterogeneity (I2: 0%) both groups were considered to have been conducted under similar conditions for fixed effect model. There was no significant difference between the success rates of LP or RALP (97.5% vs 94.8%; p = 0.21). The mean age at operation was significantly lower for LP (5.6 ± 1.8 months) than RALP (7.2 ± 1.2 months, P = 0.0001). The duration of surgery was 137 ± 45 min for LP while significantly higher at 179 ± 49 min for RALP (p = 0.0001). The mean (s.d) time to discharge was 2.0 (1.9) days for LP while 1.3 (0.4) days for RALP. The overall complication rate was significantly higher (summary table) for RALP than LP (p = 0.03), mainly due to more port-site hernias in RALP.

DISCUSSION

In the present study, we found that the success of LP and RALP in infants was similar. RALP in infants had longer duration of surgery, similar hospital stay and higher Clavien-3 complications than LP. While several studies have reported favorable outcomes for RALP over LP in children, this was not the case in infants. The smaller workspace, in an infant, can significantly limit the mobility of robotic instruments and increase the chance of port-site conflicts or trocar collisions. The use of larger robotic ports and instruments in the small space of infant abdomen might have been responsible for higher complications in RALP, including significantly larger number of port-site hernias. This meta-analysis represents the early experience of most RALP in infants, and it is possible that with experience RALP outcomes in infants also will catch up with LP. Miniaturization of robotic instruments might render RALP the future standard of care for pyeloplasty in infants.

Robot-assisted laparoscopic extravesical versus conventional laparoscopic extravesical ureteric reimplantation for pediatric primary vesicoureteric reflux: a systematic review and meta-analysis

To perform a systematic review and meta-analysis comparing the outcomes of robotic-assisted laparoscopic extravesical ureteric reimplantation (RALUR) with conventional laparoscopic extravesical ureteric reimplantation (LEVUR) for primary vesicoureteric reflux in children. We searched the databases to identify all papers of RALUR and LEVUR between 2001 and 2020. Systematic review was performed to identify patient data, age, reflux grades, laterality, duration of surgery, time to discharge, success rate and complications. Heterogeneity was reported with I² statistics and publication bias was assessed by Doi curve and Luis Furuya-Kanamori index. Pooled data from both groups were compared with Student's t test and Fisher's exact test, wherever appropriate. From a total of 43 articles screened, 28 articles were included (18 RALUR and 10 LEVUR). The I² statistics for RALUR and LEVUR showed heterogeneity of 86% and 25%, respectively. Both groups had comparable minor publication bias. RALUR had higher proportion of grade 5 VUR (p < 0.001) and bilateral reimplantations (p < 0.001). The success rate of RALUR was significantly lower than that of LEVUR (97.6% vs. 93.4%, p = 0.0018). RALUR took a significantly longer duration for surgery compared to LEVUR, both for unilateral and bilateral cases (p < 0.001). The complication rate was not significantly different: 6.6% for RALUR and 5.35% for LEVUR (p = 0.32). The most common complication in both groups was post-operative urinary retention in bilateral cases. Articles on LEVUR reported more consistent success. RALUR series had higher proportion of grade 5 cases and bilateral reimplantations. RALUR reported longer operative time and lower success compared to LEVUR, with a complication rate comparable to LEVUR.

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.

The age of robotic surgery - Is laparoscopy dead?

Introduction

Robot-assisted laparoscopic surgery (RALS) has become a widely used technology in urology. Urological procedures that are now being routinely performed robotically are: radical prostatectomy (RP), radical cystectomy (RC), renal procedures - mainly partial nephrectomy (PN), and pyeloplasty, as well as ureteric re-implantation and adrenalectomy.

Methods

This non-systematic review of the literature examines the effectiveness of RALS compared with conventional laparoscopic surgery for the most relevant urological procedures.

Results

For robot-assisted RP there seems to be an advantage in terms of continence and potency over laparoscopy. Robot-assisted RC seems equal in terms of oncological outcome but with lower complication rates; however, the effect of intracorporeal urinary diversion has hardly been examined. Robotic PN has proven safe and is most likely superior to conventional laparoscopy, whereas there does not seem to be a real advantage for the robot in radical nephrectomy. For reconstructive procedures, e.g. pyeloplasty and ureteric re-implantation, there seems to be advantages in terms of operating time.

Conclusions

We found substantial, albeit mostly low-quality evidence, that robotic operations can have better outcomes than procedures performed laparoscopically. However, in light of the significant costs and because high-quality data from prospective randomised trials are still missing, conventional urological laparoscopy is certainly not 'dead' yet.

Prospective multicenter study on robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV): Outcomes and complications

BACKGROUND

Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is a minimally invasive alternative to open surgery. We have previously reported retrospective outcomes from our study group, and herein provide an updated prospective analysis with a focus on success rate, surgical technique, and complications among surgeons who have overcome the initial learning curve.

OBJECTIVE

To assess the safety and efficacy of RALUR-EV in children, among experienced surgeons.

DESIGN AND METHODS

We reviewed our prospective database of children undergoing RALUR-EV by pediatric urologists at eight academic centers from 2015 to 2017. Radiographic success was defined as absence of vesicoureteral reflux (VUR) on postoperative voiding cystourethrogram. Complications were graded using the Clavien scale. Univariate regression analysis was performed to assess for association among various patient and technical factors and radiographic failure.

RESULTS

In total, 143 patients were treated with RALUR-EV for primary VUR (87 unilateral, 56 bilateral; 199 ureters). The majority of ureters (73.4%) had grade III or higher VUR preoperatively. Radiographic resolution was present in 93.8% of ureters, as shown in the summary table. Ureteral complications occurred in five ureters (2.5%) with mean follow-up of 7.4 months (SD 4.0). Transient urinary retention occurred in four patients following bilateral procedure (7.1%) and in no patients after unilateral. On univariate analysis, there were no patient or technical factors associated with increased odds of radiographic failure.

DISCUSSION

We report a radiographic success rate of 93.8% overall, and 94.1% among children with grades III-V VUR. In contemporary series, alternate management options such as endoscopic injection and open UR have reported radiographic success rates of 90% and 93.5% respectively. We were unable to identify specific patient or technical factors that influenced outcomes, although immeasurable factors such as tissue handling and intraoperative decision-making could not be assessed. Ureteral complications requiring operative intervention were rare and occurred with the same incidence reported in a large open series. Limitations include lack of long-term follow-up and absence of radiographic follow-up on a subset of patients.

CONCLUSIONS

Radiographic resolution of VUR following RALUR is on par with contemporary open series, and the incidence of ureteral complications is low. RALUR should be considered as one of several viable options for management of VUR in children.