Robotic-assisted Laparoscopic Approach for Posterior Bladder Neck Dissection and Placement of Pediatric Bladder Neck Sling: Initial Experience

Robotic surgery for paediatric neurogenic lower urinary tract dysfunction: a systematic review

OBJECTIVE

To evaluate in a systematic review the outcomes, benefits, and limitations of robot-assisted surgeries for paediatric neurogenic lower urinary tract dysfunction (LUTD), as robot-assisted techniques have emerged as a potential alternative, offering enhanced precision, dexterity, and visualisation.

METHODS

This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO identifier CRD42023464849) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included studies of paediatric patients (aged <18 years) with neurogenic LUTD undergoing robot-assisted continence surgery, assessing safety and efficacy. Literature searches in the Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), and Scopus were conducted until 12 July 2024. Data extraction included surgical procedures, complications, operative times, lengths of stay, and bladder function outcomes.

RESULTS

A total of 42 studies (20 case reports, 10 case series, six cohort studies, six comparative cohort studies) were included. Robotic procedures for continent catherisable channel construction, augmentation cystoplasty, and bladder neck reconstruction showed comparable peri- and postoperative outcomes. Meta-analysis of five studies comparing robotic vs open appendicovesicostomy indicated a significant reduction in length of stay for robotic groups, while operative time, complications, and re-intervention rates were not significantly different. Conversions to open surgery were rare, indicated by adhesions or small appendices during channel constructions.

CONCLUSIONS

Robot-assisted surgeries for paediatric neurogenic LUTD demonstrate potential benefits, including reduced hospital stays and comparable complication rates to open surgery in certain contexts. However, the available evidence is limited by heterogeneity in study designs, small sample sizes, and single-centre experiences, which constrain generalisability. Standardised reporting of complications and outcomes, alongside multicentre studies, is essential to clarify the long-term efficacy and broader applicability of these techniques.

Surgical Management of Neurogenic Sphincter Incompetence in Children

We report on the results of a literature review regarding the indications and results of operations to increase bladder outlet resistance to achieve dryness in children with neurogenic sphincter incompetence (NSBD). The relative advantages and disadvantages of injection of bulking agents, periurethral slings, bladder neck reconfiguration, artificial sphincters, and bladder neck closure based on a literature review and our combined clinical experience are discussed. Based on this review and our experience, we propose that periurethral injection of bulking agents is not justified as a primary treatment. Likewise, operations that reconfigure the bladder neck are not very useful since most patients also require bladder augmentation and an abdominal catheterizable channel. Bladder neck slings with autologous tissues are effective, mostly in females bur in the majority of patients a bladder augmentation is necessary. There is a role also for implantation of artificial urinary sphincters but when done as an isolated procedure, close monitoring to detect possible detrusor changes is needed. Bladder neck closure is an effective measure when other methods have failed.

Single-Site Laparoscopy and Robotic Surgery in Pediatric Urology

PURPOSE OF REVIEW

In this review, we summarize research that has evaluated the role of laparoendoscopic single-site (LESS) and robotic surgery in pediatric urology, highlighting new and/or controversial ideas.

RECENT FINDINGS

The newest research developments over the last several years are studies that address generalizability of these techniques, ideal patient factors, extrapolation to more complex surgeries, and comparative studies to more traditional techniques to define the associated costs and benefits, as well as patient-centered outcomes. Specifically in the field of LESS, addressing the limitations of suboptimal vision, instrument crowding, and loss of triangulation have been a focus. The literature is now replete with new applications for robotic surgery as well as descriptions of the specific technical challenges inherent to pediatrics. Robotic surgery and LESS are areas of growth in pediatric urology that allow continual innovation and expansion of technology within a surgeon's armamentarium.

Robotic surgery in pediatric urology

While robotic surgery has shown clear utility and advantages in the adult population, its role in pediatrics remains controversial. Pediatric-sized robotic instruments and equipment are not readily available yet, so certain modifications can be made in order to make robotic surgery successful in children. While the cost of robotic surgery remains high compared to open procedures, patients experience greater satisfaction and quality of life with robotic surgery. Robotic pyeloplasty is a standard of care in older children, and has even been performed in infants and re-do surgery. Other robotic procedures performed in children include heminephroureterectomy, ureteroureterostomy, ureteral reimplantation, urachal cyst excision, bladder diverticulectomy, and bladder reconstructive procedures such as augmentation, appendicovesicostomy, antegrade continence enema, bladder neck reconstruction and sling, as well as other procedures. Robotic surgery has also been used in oncologic cases such as partial nephrectomy and retroperitoneal lymph node dissection. Future improvements in technology with production of pediatric-sized robotic instruments, along with increases in robotic-trained pediatric urologists and surgeon experience along each's learning curve, will help to further advance the field of robotic surgery in pediatric urology.

Recent Advances in Urinary Tract Reconstruction for Neuropathic Bladder in Children

Neuropathic bladder usually causes several limitations to patients’ quality of life, including urinary incontinence, recurrent urinary tract infections, and upper urinary tract damage. Its management has significantly changed over the last few years. The aim of our paper is to address some salient features of recent literature dealing with reconstructive procedures in pediatric and adolescent patients with lower urinary tract dysfunction.

Vesicoscopic bladder neck procedure in children: what we have learned from the first series

OBJECTIVE

To assess the results of endoscopic bladder neck procedure on the anterior bladder wall in children.

MATERIALS AND METHODS

Surgery is done in the lithotomy position using three 5-mm ports. The bladder is insufflated with CO2. A U-shaped incision is made around the bladder neck. A mucosal strip is tabularized around a 12 French catheter and covered with the second layer of mucosa. Twenty procedures were performed on 18 patients (mean age, 9.8 years), and the follow-up period was >1 year (mean, 34 months). Mean operation time was 149 minutes. Twelve patients had neurogenic lower urinary tract dysfunction. Fifteen patients failed earlier bladder neck surgery, predominantly fascia sling suspension. Preoperatively, all patients had low detrusor leak point pressure. Clean intermittent catheterization (CIC) was resumed through the urethra in 11 patients and through a stoma in 6 patients.

RESULTS

Two patients needed conversion because of CO2 leakage. Six patients were dry, and 4 improved in the short term (3-6 months). After 1 year of follow-up, 2 patients were dry, and 6 improved. In the long term, 1 (9%) out of 11 patients who were catheterized through the urethra was dry, and 3 of the 11 patients (27%) improved. Of the 6 patients with a CIC stoma, 1 (17%) was dry, and 3 (50%) improved.

CONCLUSIONS

Endoscopic bladder neck surgery is, for most patients, a minor operation, but the long-term results are disappointing. The construction of a continent channel for CIC can improve the outcome when anterior bladder neck plasty is performed.

Complex robotic reconstructive surgical procedures in children with urologic abnormalities

PURPOSE OF REVIEW

Robot-assisted laparoscopic surgery (RALS) is evolving rapidly in the pediatric surgical field. The unique attributes of the robotic interface makes this technology ideal for children with congenital anomalies who often require reconstructive procedures. Furthermore, the system can generate extremely delicate movements in a confined working space such as the one generally found in the pediatric population. Herein, we critically review the current experience with RALS placing a special emphasis in children undergoing complex reconstructive surgical procedures worldwide.

RECENT FINDINGS

A total of 42 original manuscripts on a variety of robot-assisted urologic surgical procedures in children were identified from a MEDLINE database search. Complex reconstructive procedures that are being currently performed include reoperative pyeloplasty, pyeloplasty in infants, pyelolithotomy, ureteropyelostomy/ureterostomy, bladder augmentation with or without appendico-vesicostomy, bladder neck sling procedure, among others.

SUMMARY

Initial results with robot assistance are encouraging and have demonstrated safety comparable to open procedures and outcomes at least equivalent to standard laparoscopy. Future development of smaller instruments, incorporating tactile feedback, will likely overcome current limitations and spread out the use of this technique in younger children and more advanced procedures.

Preperitoneoscopic approach for bladder neck sling suspension in a boy: preliminary experience

OBJECTIVES

This report is aimed at describing our preliminary experience with the preperitoneoscopic approach to the bladder neck for rectus fascial sling suspension in neurogenic bladder.

MATERIALS AND METHODS

A 13-year-old boy with spina bifida was admitted to our institution to treat bladder incontinence. A bladder neck suspension and bladder augmentation was planned. The preperitoneal space was progressively gained by blunt dissection under direct vision (laparoscopy with a single left subcostal trocar), and a total of three preperitoneal ports were inserted. Dissection of the bladder proved to be relatively easy, and the retropubic space as well as the deep pelvis were safely exposed. Owing to the excellent endoscopic visualization, the bladder was dissected downward from the rectum. Once complete mobilization of the bladder neck was achieved, an umbilical tape was passed around the proximal urethra to create an adequate passage for the fascial sling.

RESULTS

The preperitoneoscopic procedure lasted 2 hours. No complications occurred. A good daytime dry period was achieved at the 4-month follow-up.

DISCUSSION

Direct visualization of the bladder neck and minimal dissection to the deep pelvis are the key points of this approach. Provided certain technical details are considered, the minimally invasive preperitoneal access is a valuable alternative to the open approach for the rectus fascial sling procedure, particularly when dealing with male patients. Technical advances will, presumably, lead to a complete minimally invasive treatment of urinary incontinence in male patients with spina bifida.

The urologist's role in the management of spina bifida: a continuum of care

Caring for the child with spina bifida necessitates lifelong care by a coordinated team of health care providers, and the urologist plays a vital role in this team. The most important management goal of the urologist is the early establishment and consistent maintenance of a lower pressure urinary reservoir. Ensuring social continence along with its attendant social independence provides some of the greatest management challenges. In those patients who fail medical therapy, surgeons, caregivers, and patients must understand the scope of lower urinary tract reconstruction, the need for strict compliance, and the possibility of future surgery. In this article, we review the recent advances in spina bifida management.

Robotic-Assisted Laparoscopic Surgery in Pediatric Urology: An Update

Laparoscopic procedures for urological diseases in children, such as nephrectomy, pyeloplasty and orchiopexy, have proven to be safe and effective with outcome comparable to the open procedure. However, main drawback has been the relatively steep learning curve for this procedure because of technical difficulties of suturing and anastomosis. More recently, robotic-assisted laparoscopic surgery (RAS) has gained enormous popularity in adult urology and is increasingly being adopted around the world; however, few pediatric urology series have been reported. RAS has several advantages over conventional laparoscopic surgery, with the main advantage being simplification and precision of exposure and suturing because of allowing movements of the robotic arm in real time with increased degree of freedom and magnified 3-dimentional view. These features render RAS ideal for complex reconstructive surgery in a pediatric urological population. This review discusses the role of RAS in pediatric urology, and provides some technical aspects of RAS and a critical summary of current knowledge on its indications and out-come. Almost all operations that are classically performed as open or conventional laparoscopic reconstructive surgery for children with urological anomalies could be replaced by RAS, which may be established as an alternative minimally invasive surgery in the future.

Laparoscopic approach for artificial urinary sphincter implantation in women with intrinsic sphincter deficiency incontinence: a single-centre preliminary experience

BACKGROUND

Implantation of an artificial urinary sphincter (AUS) is used as a last resort in women with stress urinary incontinence (SUI).

OBJECTIVE

To assess the early functional outcome after laparoscopic placement of an AUS in women.

DESIGN, SETTING, AND PARTICIPANTS

Twelve women with type 3 SUI underwent a laparoscopic AUS placement between 2006 and 2008. Eleven (92%) had previously undergone anti-incontinence procedures.

INTERVENTION

The AUS was implanted with laparoscopic access either preperitoneally or intraperitoneally. The cuff was placed around the bladder neck between the periurethral fascia and the vagina.

MEASUREMENTS

Perioperative complications were reviewed. To assess resolution of urinary incontinence, all patients were seen at 1, 3, 6, and 12 mo after the surgery and yearly thereafter.

RESULTS AND LIMITATIONS

The mean age of subjects was 56.7+/-12 yr (33-78). The mean body mass index was 24+/-2.3 (20-25). The mean preoperative closure pressure was 22+/-10.9 cmH(2)O (4-35). The mean operative time was 181+/-39 min [110-240]. Intraoperative complications occurred in three women (25%), with bladder (n=2) and vaginal (n=2) injuries. These complications required open conversion. AUS implantation was postponed in one case. The mean hospital stay was 7+/-2.3 d (3-11). The bladder catheter was removed after a mean time of 10+/-8 d (2-30). Urinary retention was observed in five cases (45%) after bladder catheter removal. AUS activation was done 4-14 wk after implantation. Mean follow-up was 12.1+/-8 mo (5.2-27). Incontinence was completely resolved in eight women (88%) who underwent complete laparoscopic procedure. The main limitation of the study was the limited length of follow-up.

CONCLUSIONS

AUS implantation can be successfully achieved by laparoscopy. It appears to be technically feasible. These results are still preliminary, and further studies of larger populations with longer follow-up are needed to make any statement regarding surgical strategy.