Mentored retroperitoneal laparoscopic renal surgery in children: a safe approach to learning

Laparoscopic nephrectomy in children: Does the approach matter?

INTRODUCTION AND OBJECTIVE

Laparoscopic nephrectomy (LN) is an established technique for the management of benign non-functioning kidneys in children. It can be performed either by the transperitoneal (TP) or retroperitoneal (RP) approach. The aim of this study was to compare safety and efficacy of TP with RP approach for LN in children.

STUDY DESIGN

Between 2007 and 2019, 79 consecutive pediatric patients with benign non-functioning kidneys underwent laparoscopic nephrectomy by a single surgeon. Patients were categorized into two groups according to the approach; Group 1 included 41 patients who underwent transperitoneal laparoscopic nephrectomy (TPLN), while Group 2 included 38 patients who underwent retroperitoneal laparoscopic nephrectomy (RPLN). Comparison was done between the two groups regarding the mean operative time, complications, time to resume oral intake, need for postoperative analgesia and postoperative hospital stay.

RESULTS

Laparoscopic nephrectomy was successfully completed in 75 of the 79 cases. Four cases were converted to open surgery: 3 from the TPLN group and one from the RPLN group (p = 0.34). There was statistically significant difference between the two groups in terms of estimated blood loss (p = 0.013), time to resume oral intake (p = 0.001) and postoperative hospital stay (p = 0.024). Overall, there was no statistically significant difference as regard mean operative time, overall complication rate, and postoperative analgesia need.

DISCUSSION

LN is now an established technique in children and surgeon experience is a limiting factor. This experience should be gained progressively with respect to both TP and RP approaches to deal with different indications by optimal approach. Both TP and RP approaches are excellent approaches and it is up to individual surgeons, based on their experience, which approach they select. In this study, a comparative study was made between both TP and RP approaches for pediatric LN. There was no statistically significant difference between the two approaches as regard success rate, mean operative time, need for postoperative analgesia and overall complication rate. In the meantime, RPLN had the advantage of lower intraoperative blood loss, shorter time to resume oral intake and shorter hospital stay.

CONCLUSIONS

Laparoscopic nephrectomy in children may be performed by transperitoneal or retroperitoneal approaches, obtaining equal safety and efficacy. The retroperitoneal approach seems to be advantageous in terms of lower intraoperative blood loss, time to resume oral intake and shorter postoperative hospital stay.

Implementation and Effectiveness of Coaching for Surgeons in Practice - A Mixed Studies Systematic Review

INTRODUCTION

Despite recent changes to medical education, surgical training remains largely based on the apprenticeship model. However, after completing training, there are few structured learning opportunities available for surgeons in practice to refine their skills or acquire new skills. Personalized observation with feedback is rarely a feature of traditional continuing medical education learning. Coaching has recently been proposed as a modality to meet these educational gaps; however, data are limited, and few coaching programs presently exist. The purpose of this study is to summarize the characteristics of coaching programs for surgeons in practice including participant satisfaction, program outcomes, and barriers to implementation, in the published literature.

METHODS

A mixed studies systematic review was conducted according to PRISMA guidelines to identify all original studies describing or investigating coaching for practicing surgeons up to 06/2019. Quantitative analysis was used to summarize numerical data, and qualitative analysis using grounded theory methodology for descriptive data was used to summarize the results into themes across studies.

RESULTS

After identification of articles, 27 were included in the final synthesis. Twenty-six articles described execution of a coaching program. Programs varied widely with 18/26 focusing on teaching new skills, and the remainder on refinement of skills. Thematic analysis identified 2 major data categories that guided deeper analysis: outcomes of and barriers to coaching. Of the 16 (62%) programs that reported outcomes of coaching, 42% to 100% of participants reported changes in clinical practice directly associated with coaching. Positive satisfaction after completion of a program was reported by 82% to 100% of participants. Reported barriers to participating in a coaching program emerged along 3 main themes: logistical constraints, surgical culture, and perceived lack of need.

CONCLUSIONS

Coaching for surgeons in practice is highly rated by participants and often results in clinical practice changes, while cultural and logistical issues were identified as barriers to implementation. A better understanding of these factors is required to guide coaching program development and implementation.

Structured-mentorship Program for Periacetabular Osteotomy Resulted in Few Complications for a Low-volume Pelvic Surgeon

BACKGROUND

The Bernese periacetabular osteotomy (PAO) is a complex surgical procedure with a substantial learning curve. Although larger hospital and surgeon procedure volumes have recently been associated with a lower risk of complications, in geographically isolated regions, some complex operations such as PAO will inevitably be performed in low volume. A continuous structured program of distant mentoring may offer benefits when low numbers of PAOs are undertaken, but this has not been tested. We sought to examine a structured, distant-mentorship program of a low-volume surgeon in a geographically remote setting.

QUESTIONS/PURPOSES

The purposes of this study were (1) to identify the clinical results of PAO performed in a remote-mentorship program, as determined by patient-reported outcome measures and complications of the surgery; (2) to determine radiographic results, specifically postoperative angular corrections, hip congruity, and progression of osteoarthritis; and (3) to determine worst-case analysis of PAO survivorship, defined as nonconversion to THA, in a regionally isolated cohort of patients with a high rate of followup.

METHODS

Between August 1992 and August 2016, 85 PAOs were undertaken in 72 patients under a structured, distant-mentorship program. The patients were followed for a median of 5 years (range, 2-25 years). There were 18 males (21 hips) and 54 females (64 hips). The median age of the patients at the time of surgery was 26 years (range, 14-45 years). One patient was lost to followup (two PAOs) and one patient died as a result of an unrelated event. Patient-reported outcome measures and complications were collected through completion of patient and doctor questionnaires and clinical examination. Radiographic assessment of angular correction, joint congruity, and osteoarthritis was undertaken using standard radiology software. PAO survivorship was defined as nonconversion to THA and is presented using worst-case analysis. The loss-to-followup quotient-number of patients lost to followup divided by the number of a patients converted to THA-was calculated to determine quality of followup and reliability of survivorship data.

RESULTS

The median preoperative Harris hip scores of 58 (range, 20-96) improved postoperatively to 78 (range, 33-100), 86 (range, 44-100), 87 (range, 55-97), and 80 (range, 41-97) at 1, 5, 10, and 14 years, respectively. Sink Grade III complications at 12 months included four relating to the PAO and one relating to the concomitant femoral procedure. The median lateral center-edge angle correction achieved was 22° (range, 3°-50°) and the median correction of acetabular index was 19° (range, 3°-37°). Osteoarthritis progressed from a preoperative mean Tönnis grade of 0.6 (median, 1; range, 0-2) to a postoperative mean of 0.9 (median, 1; range, 0-3). Six hips underwent conversion to THA: five for progression of osteoarthritis and one for impingement. At 12-year followup, survivorship of PAO was 94% (95% confidence interval [CI], 85%-98%) and survivorship with worst-case analysis was 90% (95% CI, 79%-96%). The loss-to-followup quotient for this study was low, calculated to be 0.3.

CONCLUSIONS

When PAO is performed using a structured process of mentoring under the guidance of an expert, one low-volume surgeon in a geographically isolated region achieved good patient-reported outcomes, a low incidence of complications at 12 months, satisfactory radiographic outcomes, and high survivorship. A structured distant-mentorship program may be a suitable method for initially learning and continuing to perform low-volume complex surgery in a geographically isolated region.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Training for MIS in pediatric urology: proposition of a structured training curriculum

In Europe there are a lot of training centers for minimally invasive surgery (MIS) but a standardized MIS training program in pediatric urology doesn't exist at the moment. We performed a literature review with the last goals to propose a structured training curriculum in MIS urology for pediatric surgeons. Pediatric urologists have to obtain a valid MIS training curriculum completing the following 4 steps: (I) Theoretical part (theoretical courses, masterclass) to acquire theoretical knowledge; (II) experimental training (simulation on pelvic trainer, virtual reality simulators, animal models, 3-D ex-vivo models) to acquire basic laparoscopic skills; (III) stages in European centers of reference for pediatric MIS urology to learn all surgery aspects; (IV) personal operative experience. At the end of the training period, the trainee would be expected to perform several MIS urological procedures independently, under supervision of an expert tutor. At the end of the training program, each center will analyze the candidate training booklet and release for each applicant a certification after an exam. We think that this MIS training program in pediatric urology may assure an integrated acquisition of basic and advanced laparoscopic skills during residency training in pediatric urology. Each European country should adopt this program so as to secure a standardized technical qualification in MIS urology for all future pediatric urologists.

Mentoring in complex surgery: minimising the learning curve complications from peri-acetabular osteotomy

PURPOSE

The aim of this study was to determine whether a complex surgical procedure such as peri-acetabular osteotomy could be safely learnt by using a programme involving mentoring by a distant expert. To determine this, we examined the incidence of intra-operative complications, the acetabulum correction achieved, the late incidence of re-operation and progressive degenerative arthritis.

METHODS

Between 1992 and 2004, peri-acetabular osteotomy was performed in 26 hips in 23 patients. The median follow-up was ten (5-17) years. The median age of the patients at operation was 28 (14-41) years. Clinical outcomes were reported and radiographic results were determined by an independent expert.

RESULTS

There were no intra-articular osteotomies, sciatic nerve injuries, hingeing deformities or vascular injuries. There was one ischial nonunion. The lateral centre-edge angle improved from a median 4° pre-operatively to 25°. One revision osteotomy, one osteectomy and three total hip replacements were required, two for progression of osteoarthritis.

CONCLUSIONS

The programme of mentoring was successful in that there was a low incidence of the major intra-operative complications that are often reported during the learning curve period and the acetabular corrections achieved were similar to the originators.

The evolving role of laparoscopic surgery in paediatric urology

OBJECTIVES

We review the various applications of laparoscopic and robotic-assisted laparoscopy in paediatric urology, as the laparoscopic and robotic approach in this population is gradually being recognised.

METHODS

We searched PubMed for human studies in English that were published between 1990 and the present, focusing on laparoscopic nephrectomies and partial nephrectomies, laparoscopic and robotic pyeloplasties and ureteric reimplantation, laparoscopic orchidopexy and varicocelectomy. We also reviewed robotic-assisted laparoscopic urological major reconstructions. Key articles were reviewed, extracting the indications, techniques, and the advantages and disadvantages.

RESULTS AND CONCLUSIONS

Laparoscopy has a defined place in modern paediatric urological surgery. Laparoscopic nephrectomies, pyeloplasties and abdominal exploration for the evaluation and management of impalpable undescended testicles have become the standard of care. Robotic-assisted laparoscopic surgery is developing as a safe and effective option even for infant patients.

Open versus prone retroperitoneoscopic partial nephrectomy in children: a comparative study

PURPOSE

To compare the outcomes of open (OPN) and prone retroperitoneoscopic partial nephrectomy (PRPN) in children.

MATERIALS AND METHODS

The medical and radiological records of all children undergoing OPN and PRPN over a 6-year period (2002-2008) were reviewed.

RESULTS

Thirty-nine (11 boys/28 girls) partial nephrectomies were performed in a single institution. There were 24 OPNs (15 upper, 9 lower) and 15 PRPNs (13 upper, 2 lower) with a median age at surgery of 2.3 years and 3.4 years, respectively. Median duration of surgery was 50 min (range 30-180) for the OPN and 150 min (range 70-205) for the PRPN (P < 0.001). Median postoperative hospital stay was 4 days (range 2-7) for the OPN and 2 days (range 1-5) for the PRPN (P < 0.001). One patient in the OPN underwent a total nephrectomy with a loss of the remaining moiety. In 20 (87%) patients of the OPN group an epidural infusion was administered and four required a morphine infusion, while only five patients in the PRPN group required a morphine infusion.

CONCLUSIONS

Open partial nephrectomy had a significantly shorter operative time, but it was associated with a longer postoperative stay and higher analgesia requirements when compared to PRPN.

[Complications in laparoscopy renal surgery in pediatric age: analysis of our experience and literature review]

INTRODUCTION

The development of the minimally invasive surgery in pediatric age has been slower than in the adult age since their advantages are not so clear. The learning curve and the complications presented during this period, as well as the type of material used has been the factors that have contributed to this fact.

OBJECTIVE

We collected our experience and the complications presented in renal laparoscopic exegesis surgery, adding a review of the published literature to date.

MATERIALS AND METHODS

Retrospective study of our clinical cases in that we practiced laparoscopic renal exegesis surgery. We collected 56 cases from January 2003, when it was implanted, to September 2008. We had 36 boys (64%) and 20 girls (36%). The mean age was 3.6 years. We analyzed principal diagnosis, the situation that conducted to the surgery and the type of surgery performed, time of surgery, hospital stay and complications with their solution. The results were analyzed the statistical program SPSS (SPSSCorp, Chicago, Illinois). The literature review was practiced in MEDLINE, EMBASE and COCHRANE database. The selected works were reviewed by two investigators. Series containing adults were excluded.

RESULTS

We perfomed 42 nephrectomies (75%), 13 heminephrectomies (23%) and 1 quistectomy (2%). 5 cases (9%) were done by retroperitoneoscopy and 51 cases (91%) transperitoneally. The mean operative time was 118 +/- 0,75 min, for nephrectomies; 192 +/- 1.07 min, for partial nephrectomies, 111 +/- 0,64 for nephroureterectomies and 240 min for quistectomia. The mean hospital stay was 3.18 min (2-6) days for nephrectomies; 5.91 (3-11) days for partial nephrectomies, 3 days (2-4) for nephroureterectomies and 6 days for the quistectomy. We had 8 complications (14%): 2 conversions for bledding and technical difficulty and 6 postoperative complications (3 were minor complications, postoperative fever and 3 mayor (2 Urinomas and one pseudoaneurism, requiring 2 interventions and one catheter double J placement). The evolution has been satisfactory in all cases. In the bibliographic review 47 articles with a level of evidence IIIB were selected (Oxford Centers for Evidence-based Medicine). The main reasons to conversion to open surgery were vascular problems and the complication rate change from anyone to 37%.

CONCLUSIONS

Laparoscopic surgery has proved to be a secure and feasible technique in the treatment of benign renal pathology in pediatric age with satisfactory results. Actually the indications are expanding to reconstructive procedures, with promising results, and selected oncologic procedures.

Robot-assisted laparoscopic pyeloplasty: outcomes reported by a centre with no previous laparoscopic experience

Laparoscopic pyeloplasty (LP) has proved to be an effective minimally invasive treatment for ureteropelvic junction obstruction (UPJO). However, its application is still limited by the challenge of the laparoscopic learning curve, which seems to be overcome by the recent introduction of robot assistance. The aim of this manuscript is to show our outcomes after the first robot-assisted laparoscopic pyeloplasties (RP) and critically evaluate the feasibility of this technique when performed by a surgical team without any previous laparoscopic experience. Between March 2005 and July 2008, 16 patients with UPJO underwent transperitoneal RPs. Before and after surgery patients were evaluated by ultrasonography, intravenous urography or retrograde pyelography, computed tomography (CT) scan, and/or diuretic renography. Mean follow-up was 16.8 months. The assessed outcomes were mean operative time (OT), mean estimated blood loss (EBL), mean length of hospital stay (LOS), success (SR), and complication rates (CR). OT, EBL, LOS, and SR were 202 min, 60 ml, 5.2 days, and 94%, respectively. Among the minor complications, two patients (12%) reported moderate abdominal pain while, concerning major complications, one patient (6%) developed ileus. Robot assistance was confirmed as a special tool for laparoscopic treatment of UPJO with excellent outcomes after a shorter learning curve. As shown by our results, the feasibility of RP may also be extended to naïve surgeons who can approach this technique even in the absence of previous laparoscopic training, rapidly attaining results similar to those reported by both laparoscopically experienced and expert robotic surgeons.

Review of laparoscopic training in pediatric surgery in the United Kingdom

AIM

To review the exposure pediatric surgery trainees have to laparoscopic surgery in the United Kingdom (UK).

METHODS

A confidential postal questionnaire was sent to all trainees working at registrar level in centers responsible for pediatric surgical training in the UK. Questions assessed the number of consultants with an interest in laparoscopic surgery, types of cases performed laparoscopically, and trainees' role in laparoscopic appendicectomy (LA).

RESULTS

Questionnaires were sent to 112 trainees with a 55% response rate (62 replies). At least one response was received from each unit. Based on responses, 49 to 67 consultants in 21 training centers have an interest in laparoscopic surgery (0%-100% of consultants per unit). LA was offered in 20 out of 21 training centers. There was no significant difference in the proportion of appendicectomies performed laparoscopically by junior (years 1-3) and senior (years 4-6) trainees. A significantly higher proportion of junior trainees had not performed any LAs (P = 0.02). Seventy-three percent of trainees were the principal operator. For trainees who were principal operators, the cameraperson was a consultant in 52% and a junior trainee in 17%. The time of day affected the likelihood of a procedure being carried out laparoscopically in 43 (81%) responses.

CONCLUSIONS

The majority of trainees' exposure to laparoscopic surgery could be viewed as suboptimal; however, the exposure gained varies significantly between different units throughout the UK. In an age moving in favor of minimal access surgery, all units must be in a position to offer pediatric laparoscopic surgical training.

Pediatric Laparoscopic Pyeloplasty in a Referral Center: Lessons Learned

PURPOSE

We present our first-year experience with pediatric transperitoneal laparoscopic dismembered pyeloplasty (TLDP) in a large referral center.

PATIENTS AND METHODS

A chart review was conducted in 27 consecutive children (M:F 23:4) aged 4 to 17 years (mean 9.7 years) with ureteropelvic junction obstruction who underwent TLDP (21 on the left, 6 on the right) in 2005. The key steps implemented to facilitate and streamline this procedure were: (1) clamping the Foley catheter before surgery to distend the renal pelvis and facilitate the transmesenteric approach; (2) stabilizing the renal pelvis with a traction suture; (3) performing the dismembered pyeloplasty using a modified double-armed suture; and (4) placing the ureteral stent percutaneously antegrade before completing the anastomosis. Operative time, hospital stay, complications, and follow-up radiologic studies were reviewed.

RESULTS

The TLDP was performed with no open conversions. Crossing vessels and horseshoe kidney were present in 8 patients and 2 patients, respectively. The mean operative time was 221 minutes. Stent insertion was successful in all but one patient. Postoperative pain management was successful in all 27 patients. There were 4 postoperative complications (14.8%) consisting of prolonged leakage in two, obstruction in one, and obstruction with pyelonephritis in one. These last two complications occurred early in our experience and were treated successfully by percutaneous nephrostomy with subsequent retrograde endopyelotomy. The average hospital stay was 2.1 days (range 1-4 days). Radiologic studies 8 to 20 months after removal of the Double-J stents showed reduction of the degree of hydronephrosis in all patients.

CONCLUSION

Our 1-year experience with TLDP gave us the opportunity to implement key steps to establish a standardized technique for this procedure. Although the follow-up period was short, most complications occurred early in this series, demonstrating that a learning curve is inevitable.

Laparoscopy in paediatric urology: present status

The spectrum of laparoscopic surgery in children has developed dramatically; what was initially used as a diagnostic method to identify an impalpable testis is now commonly used for complex reconstructive procedures such as pyeloplasty. Laparoscopic orchidopexy and nephrectomy are well established and are used at many centres. Laparoscopic partial nephrectomy, adrenalectomy and dismembered pyeloplasty series have reported shorter hospital stays and operative times that are comparable with that of open techniques, and/or decreasing with experience. The initial experiences with laparoscopic ureteric re-implantation and laparoscopically assisted bladder reconstructive surgery are reported, with encouraging results for feasibility, hospital stay, and cosmetic outcome.

Optimizing Outcomes in Laparoscopic Urologic Training: Toward A Standardized Global Consensus

BACKGROUND AND PURPOSE

Laparoscopic urologic surgery (LUS) is one of the fastest growing subspecialties in the surgical world. The procedures require technical expertise and finesse; unlike their open counterparts, there is significant limitation in the margin for error. Various ethical, medicolegal, and health economy demands have made training in laparoscopic urologic surgery challenging. Whereas several groups have sought solutions through models, there remains a lack of consensus on the optimal training program. We review the current LUS programs with a conscious effort to decipher the basic tenets of an optimal training program and propose training models based on published evidence, in conjunction with current trends in LUS.

METHODS

A literature search of MEDLINE, Pubmed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, and Google Scholar was performed, seeking publications from January 1970 to July 2006 on laparoscopic surgical training pertaining to urology. Additionally, we looked at pertinent abstracts of the annual meetings of the American Urological Association, the European Association of Urology, and the World Congress of Endourology for the period January 1996 to and inclusive of August 2006.

RESULTS AND CONCLUSIONS

To date, no study has documented a global consensus on optimal LUS training programs. Our search identified several models, some of which were applied successfully in the form of minifellowships. There remain no clear guidelines on the optimum LUS training program. The optimal program may need to be tailored to individual units, based on resources (this includes country-specific health economics, mentor availability, and caseload). Further studies are needed to help elucidate how individual programs can be initiated with a global minimum standard applicable to all training programs.

Minimally invasive surgery for urologic disease in children

This article is a comprehensive review of the current indications and recent literature pertaining to laparoscopic techniques in pediatric urology. Basic concepts such as instrumentation, anesthetic considerations, and complications are reviewed. Specific techniques and indications are also explored. As the field of pediatric urology continues to expand, it still lags behind adult urology. With improvements in technology, however, and with new surgeons entering the field with a basic laparoscopic background, pediatric urologic laparoscopy continues to progress. Currently, procedures such as laparoscopic exploration for undescended testicles and laparoscopic nephrectomy are accepted as the 'gold standard', and are performed at most institutions. Other procedures, such as laparoscopic pyeloplasty and laparoscopic reconstructive surgery, have only recently been introduced and are primarily available at centers with surgeons experienced in laparoscopy. It is our hope that minimally invasive surgical approaches to urologic conditions will become available to all children and become commonplace at most institutions.

Retroperitoneal laparoscopic nephrectomy in children: at last the gold standard?

PURPOSE

We analyzed our experience with retroperitoneal laparoscopic nephrectomy giving special attention to the learning curve, morbidity, and feasibility in a teaching institution.

MATERIAL AND METHODS

Between 1996 and 2004, we performed 104 laparoscopic nephrectomies in 88 children. Only four were performed via the transperitoneal approach, the others being via the retroperitoneal approach; the files of the latter were analyzed. Mean age was 5 years (20 days-15 years). Main indications were pretransplant nephrectomy for arterial hypertension, nephrotic syndrome or uremic hemolytic syndrome (51%), non-functioning kidney secondary to obstruction, reflux or ectopic ureter (38%), and multicystic dysplastic kidney (11%). Bilateral nephrectomy was performed in 13 children.

RESULTS

The lateral retroperitoneal approach was feasible in all cases even for those who had previous renal surgery. Conversion was not needed in any patient. No significant blood loss was observed. Mean operative time was 97 min (range 44-240) for unilateral nephrectomy; 46 nephrectomies were done in less than 90 min. In bilateral cases the mean operative time was 260 min (range 160-390). The operative time was less than 4 h in seven bilateral cases. Postoperative course was uneventful. Hospital stay was 1.9 days (range 1-3) for urological indications and 5 days (range 3-7) for patients with terminal renal disease. The procedure was initially performed by one surgeon, but was then expanded to other surgeons of the team, and safely taught to residents and fellows.

CONCLUSIONS

The procedure is safe, the learning curve is reasonable, teaching is feasible, operating time becomes with experience closer to open surgery without morbidity, and cosmetic results are excellent. This procedure may be considered as the gold standard for nephrectomy in children.

Training in laparoscopic urology

PURPOSE OF REVIEW

Training in laparoscopy has become an important issue in the current surgical scenario. In this overview we aim to update the current knowledge in the field of laparoscopic urological training and to highlight the potential dangers of using simulation for accreditation and selection purposes at this stage.

RECENT FINDINGS

Physical simulators are widely available and seem to be equally efficient as virtual reality simulators. Transfer of training has been proven to be beneficial in randomized controlled trials for virtual reality and cholecystectomy. A model for the vesico-urethral suture has been described and integrated in a skills laboratory program. The program has construct validity and can discriminate at least between beginners and advanced laparoscopists. Efforts have still to be made in defining appropriate tools to assess competence and evidence for reliability, and validity must be obtained before including simulators in accreditation programs.

SUMMARY

In spite of the abundant literature there is still little evidence about the learning mechanism involved in acquiring laparoscopic skills. Physical and virtual reality simulators have been proven to be efficient in improving dexterity and some evidence exists of a positive transfer from virtual reality to the operating room in cholecystectomy. Very few models, however, have been described for reconstructive urology, and effective transfer to the operating room has not yet been proven, although validation work is in progress in the field of urology.

Initial comparison of robotic-assisted laparoscopic versus open pyeloplasty in children

OBJECTIVES

To compare the initial results of robotic-assisted laparoscopic versus open pyeloplasty in children with ureteropelvic junction obstruction.

METHODS

From June 2002 to July 2004, 8 pediatric patients underwent robotic-assisted laparoscopic pyeloplasty and were matched by age group with patients undergoing conventional open pyeloplasty. The mean age was 11.5 years (range 6.4 to 16.5) in the robotic-assisted group and 9.8 years (range 6.0 to 15.6) in the open group. A four-port transperitoneal technique was used to perform the Anderson-Hynes pyeloplasty with the da Vinci Surgical System.

RESULTS

The mean operative time and estimated blood loss was 363 minutes (range 255 to 522) and 13.1 mL (range 5 to 25) in the robotic-assisted group versus 248 minutes (range 144 to 375) and 53.8 mL (range 5 to 200) in the open group, respectively. The mean length of hospitalization and pain medication use was 2.4 days (range 1 to 5) and 7.4 mg morphine (range 0 to 23) in the robotic-assisted group compared with 3.3 days (range 1 to 8) and 22.0 mg morphine (range 0 to 100) in the open group, respectively. At a mean follow-up of 14.7 months (range 2 to 24), all robotic procedures were successful as determined by subjective data using pain scales and radiologic data.

CONCLUSIONS

Robotic-assisted laparoscopic pyeloplasty appears to decrease the length of hospitalization and use of pain medication, but has a longer operative time. Additional clinical experience is required to determine the long-term efficacy of this method.

The laparoscopic nephrectomy learning curve: a single centre's development of a de novo practice

OBJECTIVE

There has been a dramatic increase in the interest and practice of laparoscopic urology, with nephrectomy having become the commonest laparoscopic urological procedure. Compared with open nephrectomy, it results in reduced morbidity and shorter convalescence times while maintaining oncological safety. However, while these results predominately stem from institutions with well developed laparoscopic programmes, little is known about the results in centres that have newly adopted this technique. The introduction of a laparoscopic urological service at the Royal Hallamshire Hospital provided an opportunity to study these factors.

METHODS

Since the appointment in October 2000 of a urological surgeon (N Oakley) to develop the laparoscopic service, there have been over 200 laparoscopic procedures including 121 nephrectomies performed at this centre. Full details were collected for each of these cases, and in addition, compared with retrospective data for 50 open nephrectomies performed during the same time period.

RESULTS

With increased operator experience the median operative duration, complication, transfusion, and conversion rates significantly improved. While a learning curve was evident, the overall operative complication (9%) and conversion rates (6%) were low, in addition to patient morbidity (16.5%) and mortality (0%) rates, showing that this learning curve had no deleterious effects upon patient care. The median hospital stay was four days, which reduced to three with experience and was significantly shorter than for open nephrectomy at this institution (p = 0.001).

CONCLUSIONS

The development of a successful laparoscopic programme can be achieved with a comparatively short learning curve and without detriment to the patient provided the necessary steps are observed.

Training in laparoscopic renal surgery, in a few weeks of intense exposure

OBJECTIVES

Laparoscopic renal surgery has only recently become popular in the UK and, still, only a handful of pediatric urologists are offering the laparoscopic approach to their patients; therefore, there are only limited places available for training in this discipline. In this institution, which is a major tertiary referral center for pediatric urology having four consultants, one urologist specializes in laparoscopic renal surgery and about 50 laparoscopic ablative renal surgical procedures are performed annually. The aim of this study was to determine the effectiveness of the training provided, for three trainees, in light of the complexity of the ablative procedures performed.

PATIENTS AND METHODS

Patients who required laparoscopic ablative renal surgery from June 2003 to May 2004 were identified from the prospectively maintained database and data were analyzed. During this period of 12 months, 49 operations have been performed laparoscopically. There were three trainees, A, B and C, who joined the mentor, at different times, for a continuous period of 6, 12 and 6 weeks, respectively. The training was one to one and, at an appropriate level of expertise, the trainees were allowed to perform operations independently; they continued to do so after returning to their units.

RESULTS

There were 22 males and 27 females, age ranging from 8 months to 16 years (mean 3.6 years). There were 25 nephrectomies, 23 via the prone retroperitoneal (PRP) approach and two via the transperitoneal (TP) approach; the mean time taken was 70 min. There were 12 nephroureterectomies, six via the PRP, three via the TP, and the other three via the lateral retroperitoneal (LRP) approach; the mean time taken was 100 min. There were 10 heminephroureterectomies (six upper pole and four lower pole), six via the PRP, three via the TP and one via the LRP approach; the mean time taken was 160 min. Of two bilateral nephrectomies one was via the PRP and one the TP approach, and the mean time taken was 170 min. The mean time to discharge for nephrectomy was 7 h, and for nephroureterectomy, heminephroureterectomy and bilateral nephrectomy 21, 23 and 43 h, respectively. Trainee A had been in pediatric surgery for 4 years and during a period of 6 weeks he assisted in five operations, but did not get the opportunity to perform independently. Trainee B had been in pediatric surgery for 13 years and during a period of 12 weeks he assisted in nine operations and performed three. Trainee C had been in pediatric surgery for 20 years and during a period of 6 weeks he assisted in five operations and performed one. Since returning to their overseas units, trainee B and trainee C have successfully performed two nephrectomies each.

CONCLUSION

Retroperitoneoscopic renal surgery is within the grasp of any experienced urologist or urology trainee. With intensive exposure and one-to-one mentoring, 6-12 weeks would be sufficient to achieve adequate competence and confidence to perform a prone retroperitoneoscopic nephrectomy.

RETROPERITONEAL LAPAROSCOPIC VERSUS OPEN PYELOPLASTY IN CHILDREN

PURPOSE

The indications for laparoscopy in pediatric urology are expanding and yet the advantages over open surgery remain unclear. We compared the results of retroperitoneal laparoscopic vs open pyeloplasty for pyeloureteral junction obstruction in children.

MATERIALS AND METHODS

A total of 22 children with a mean age of 88 months (range 25 to 192) underwent laparoscopic dismembered pyeloplasty via the retroperitoneal approach. An additional 17 children with a mean age of 103 months (range 37 to 206) underwent similar procedures via open surgery through a flank incision. We retrospectively analyzed and compared operative time, the use of analgesics (acetaminophen or morphine derivatives) and hospital stay.

RESULTS

The 2 groups were similar in mean age and weight at surgery. Mean operative time was significantly shorter in the open surgery vs the laparoscopy group (96 minutes, range 50 to 150 vs 219, range 140 to 310, p <0.0001). Mean postoperative use of acetaminophen (1.9 vs 3.22 days, p = 0.03) and morphine derivatives (1.9 vs 3.06 days, p not significant) was less in the laparoscopy group. Mean hospital stay was shorter in the laparoscopy group than in the open surgery group (2.4 days, range 1 to 5 vs 5, range 3 to 7, p <0.0001). Mean followup was 21 (range 12 to 51) and 24 months (range 12 to 60) in the open and laparoscopy groups, respectively.

CONCLUSIONS

The operative time of laparoscopic pyeloplasty remains significantly longer than that of the open procedure in children. The main advantage of the laparoscopic approach is that it significantly decreases hospital stay compared with that after an open procedure. Although in our study analgesic use was less after laparoscopy, our results should be confirmed by a prospective, randomized study.

Laparoscopic management of hydronephrosis in children

The postnatal management of prenatally detected hydronephrosis mainly involves a close follow-up with ultrasound, renal isotopic scan and URO-MRI. In some cases, there is an indication for either a pyeloplasty or, more exceptionally, nephrectomy of a non-functioning obstructed kidney. In this chapter, we review the indications and the operative techniques of laparoscopic pyeloplasty in children.