Robot-Assisted Urologic Surgery: Safety and Feasibility in the Pediatric Population

Can a flexible surgical robot be used in the pediatric population: A feasibility study

OBJECTIVES

Transoral robotic surgery in adults confers excellent results and decreased morbidity. Application of these techniques has not yet been rigorously investigated in children. The goal of this study is to evaluate the feasibility of a flexible robotic surgical system in a pediatric population.

METHODS

This was a non-randomized, non-blinded, prospective clinical trial. An Investigational Device Exemption was obtained from the FDA. Patients 8-12 years old scheduled for tonsillectomy and adenoidectomy between February and December 2019 at an academic tertiary care children's hospital were included. Exclusion criteria included pulmonary or vascular conditions posing risks for extended anesthesia, or a smaller mouth opening than the instrumentation (28 mm × 15 mm). Tonsillectomy was completed with standard monopolar cautery. After the surgery was complete, the robot was utilized for evaluation and assessment of exposure. A pediatric anesthesiologist screened patients for tolerance of additional anesthesia (up to 15 min). A flexible robotic surgical system, the MedRobotics Flex® Robotic System, was used to visualize and access the tonsillar fossa, posterior pharynx, base of tongue, epiglottis and false vocal folds. Visualization and access were graded on a five-point Likert scale.

RESULTS

A total of ten patients, eight males and two females, with obstructive sleep apnea (OSA) or sleep disordered breathing (SDB) were recruited in 2019. One patient did not complete the study due to equipment malfunction. The average patient demographics were: age 10.1 years (8.6-11.8 years), height 142.4 cm (127-164.9 cm), weight 47.5 kg (24.4-84.5 kg), and BMI 22.6 (13.9-31.0). Study time averaged 10.3 min (5-13 min). The tonsillar fossa, base of tongue, and posterior pharynx were visualized completely and easily accessed with the robotic instruments. The epiglottis and false vocal folds were visualized and accessed in 66% and 55% of patients, respectively. There were no adverse effects.

CONCLUSIONS

This study demonstrated that a flexible robotic surgical system is feasible for use in children 8-12 years of age when performing otolaryngology - head and neck surgery procedures of the oropharynx and larynx.

Ten years of paediatric robotic surgery: Lessons learned

Background

Costs and a low total number of cases may be obstacles to the successful implementation of a paediatric robotic surgery programme. The aim of this study was to evaluate a decade of paediatric robotic surgery and to reflect upon factors for success and to consider obstacles.

Materials and Methods

All children operated on with robotic‐assisted laparoscopic surgery between 2006 and 2016 were included in a retrospective, single‐institutional study in Lund, Sweden.

Results

A total of 152 children underwent robotic surgery during the study time with the most frequent procedures being fundoplication (n = 55) and pyeloplasty (n = 53). Procedure times decreased significantly during the study period. Overall, 18 (12%) of the operations were converted to open surgery, and seven (5%) patients required a reoperation.

Conclusions

Despite a low volume of surgery, we have successfully introduced robotic paediatric surgery in our department. Our operative times and conversion rates are continuously decreasing.

Systematic Review and Meta-Analysis of Pediatric Robotic Assisted Laparoscopic Pyeloplasty (RALP)

INTRODUCTION

To perform a systematic review and meta-analysis of outcomes of robotic-assisted laparoscopic pyeloplasty for UPJ obstruction in children.

EVIDENCE ACQUISITION

A systematic review of the English-language literature on surgical techniques and perioperative outcomes of robotic-assisted laparoscopic pyeloplasty for UPJ obstruction in children was performed without time filters using the MEDLINE (via PubMed), EMBASE, and Cochrane databases in July 2020 according to the PRISMA statement recommendations.

EVIDENCE SYNTHESIS

Overall, 58 studies were selected for qualitative analysis, 46 of which were included in the meta-analysis. Nearly all studies included were observational and retrospective, either cohort or case-control. The quality of evidence was assessed using Modified Newcastle Ottawa Scoring, with the majority of studies scoring medium or high quality. The mean success rate was 95.4% (CI 91.0-99.3%), over a wide age range. There was a noticeable heterogeneity in reported follow up length and definitions of success rate. The majority of studies reported length of stay of ~1 day. The mean overall complication rate was 12%. For studies that reported complication rate by grade, the mean low Clavien grade (grade 2 or less) complication rate was 9.3% and the mean high Clavien grade (grade 3 or more) complication rate was 6.5%.

CONCLUSIONS

Robotic assisted surgery is technically feasible and has been shown to achieve very favorable outcomes for pyeloplasty in children. The evidence however is mostly retrospective and from single sites, which introduces potential biases. Further research is needed to further elucidate RALP benefits compared to the open and laparoscopic approach. As a RCT may not be practical in this space, perhaps a prospective multi-institutional design with a uniform reporting system of pediatric RALP is the next step to define its benefits and limits.

Robotic-Assisted Minimally Invasive Surgery in Children

Currently, minimally invasive surgery (MIS) includes conventional laparo-thoracoscopic surgery and robot-assisted surgery (RAS) or robotic surgery. Robotic surgery is performed with robotic devices, for example the Da Vinci system from Intuitive Surgical, which has a miniaturized camera capable of image magnification, a three-dimensional image of the surgical field, and the instruments are articulated with 7 degrees of freedom of movement, and the surgeon operates in a sitting position at a surgical console near the patient. Robotic surgery has gained an enormous surge in use on adults, but it has been slowly accepted for children, although it offers important advantages in complex surgeries. The areas of application of robotic surgery in the pediatric population include urological, general surgery, thoracic, oncological, and otorhinolaryngology, the largest application has been in urological surgery. There is evidence that robotic surgery in children is safe and it is important to offer its benefits. Intraoperative complications are rare, and the frequency of postoperative complications ranges from 0–15%. Recommendations for the implementation of a pediatric robotic surgery program are included. The future will be fascinating with upcoming advancements in robotic surgical systems, the use of artificial intelligence, and digital surgery.

Robot-Assisted Laparoscopic and Thoracoscopic Surgery: Prospective Series of 186 Pediatric Surgeries

Objective: We present the applications and experiences of robot-assisted laparoscopic and thoracoscopic surgery (RALTS) in pediatric surgery. Materials and Methods: A prospective, observational, and longitudinal study was conducted from March 2015 to March 2018 that involved a non-random sample of a pediatric population that was treated with RALTS. The parameters examined were: gender, age, weight, height, diagnoses, surgical technique, elapsed time of console surgery, estimated bleeding, need for hemotransfusion, complications, surgical conversions, postoperative hospital stay, and follow-up. The Clavien-Dindo classification of complications was used. The surgical system used was the da Vinci model, Si version (Intuitive Surgical, Inc., Sunnyvale, CA. U.S.A), with measures of central tendency. Results: In a 36-months period, 186 RALTS cases were performed, in 147 pediatric patients and an adult; 53.23% were male, and the remaining were female. The average age was 83 months, ranging from 3.5 to 204 months, plus one adult patient of 63 years. The stature was an average of 116.6 cm, with a range of 55-185 cm; the average weight was 26.9 kg, with a range of 5-102 kg; the smallest patient at 3.5 months was 55 cm in stature and weighed 5.5 kg. We performed 41 different surgical techniques, grouped in 4 areas: urological 91, gastrointestinal and hepatobiliary (GI-HB) 84, thoracic 6, and oncological 5. The console surgery time was 137.2 min on average, ranging from 10 to 780 min. Surgeon 1 performed 154 operations (82.8%), and the remainder were performed by Surgeon 2, with a conversion rate of 3.76%. The most commonly performed surgeries were: pyeloplasty, fundoplication, diaphragmatic plication, and removal of benign tumors, by area. Hemotransfusion was performed for 4.83%, and complications occurred in 2.68%. The average postoperative stay was 2.58 days, and the average follow-up was 23.5 months. The results of the 4 areas were analyzed in detail. Conclusion: RALTS is safe and effective in children. An enormous variety of surgeries can be safely performed, including complex hepatobiliary, and thoracic surgery in small children. There are few published prospective series describing RALTS in the pediatric population, and most only describe urological surgery. It is important to offer children the advantages and safety of minimal invasion with robotic assistance; however, this procedure has only been slowly accepted and utilized for children. It is possible to implement a robust program of pediatric robotic surgery where multiple procedures are performed.

Our experiences with robot- assisted laparoscopic surgery in pediatric patients: the first case series from Turkey

OBJECTIVE

Robotic surgery is a leading treatment option for minimally invasive surgery and has an increasing popularity in pediatric population, as well. In this article, we reported our case series of robot-assisted laparoscopic surgery in pediatric population.

MATERIAL AND METHODS

We retrospectively reviewed 29 consecutive pediatric patients who underwent robot- assisted procedures between May 2014 and October 2016. Patient demographics, hospitalization time, estimated blood loss, robotic time and total operative and peri-, and post-operative complications were evaluated.

RESULTS

A total of 24 ureter units (18 patients) with grade 1-5 vesicoureteral reflux in 13 female and 5 male, 1 male patient with vesicoureteral stenosis were underwent robot- assisted laparoscopic ureteral reimplantation (RALUR). All patients had complete resolution after surgery. Robot-assisted laparoscopic pyeloplasty (RALP) was performed in 6 patients with ureteropelvic junction obstruction. All patients had complete resolution after surgery. Completely intracorporeal robotic assisted laparoscopic augmentation ileocystoplasty (RLAIC) was applied to two patients with neurogenic bladder. The symptoms and preoperative hydronephrosis were regressed on the first month of follow-up. Robot-assisted laparoscopic reduction cystoplasty (RALRC) was performed in 14-year-old boy with a bladder diverticula and recurrent urinary tract infection. The last case was eleven- year-old female patient with non-functioning kidney. She had recurrent urinary tract infections and was treated with robotic assisted laparoscopic nephrectomy (RALN).

CONCLUSION

Robot-assisted laparoscopic surgery is safe and efficient in pediatric population. Although open surgery is still the gold standard for many pediatric diseases, inherent reconstructive advantages of robotic assisted laparoscopy have a chance to change this view.

The Nonpalpable Testis: A Narrative Review

PURPOSE

While the nonpalpable testis represents a small portion of all cryptorchid testes, it remains a clinical challenge for pediatric urologists. Controversy exists surrounding the best evaluation and management of this entity. In this review we update what is known about the nonpalpable testis, including the etiology, preoperative evaluation and best surgical management as well as novel techniques and ongoing controversies.

MATERIALS AND METHODS

We searched PubMed® and MEDLINE® from January 2000 to January 2017 using relevant key terms. Of 367 articles 115 were considered for inclusion based on a priori design. Using a narrative review format, an update on the evaluation and management of the nonpalpable testis including novel concepts and techniques was synthesized.

RESULTS

The nonpalpable testis should be evaluated by physical examination only. Imaging is not indicated for routine cases. The optimal surgical approach and technique remain debatable but several novel techniques have been described. Due to the rarity of the nonpalpable testis, randomized controlled trials and other quality comparisons are difficult. Therefore, management remains controversial.

CONCLUSIONS

Evaluation and management of the nonpalpable testis remain difficult, and some aspects are still debated. Future research should focus on multi-institutional collaborative trials to determine the optimal operative management.

How to successfully implement a robotic pediatric surgery program: lessons learned after 96 procedures

BACKGROUND

Both our teams were the first to implement pediatric robotic surgery in France. The aim of this study was to define the key points we brought to light so other pediatric teams that want to set up a robotic surgery program will benefit.

METHODS

We reviewed the medical records of all children who underwent robotic surgery between Nov 2007 and June 2011 in both departments, including patient data, installation and changes, operative time, hospital stay, intraoperative complications, and postoperative outcome. The department's internal organization, the organization within the hospital complex, and cost were evaluated.

RESULTS

A total of 96 procedures were evaluated. There were 38 girls and 56 boys with average age at surgery of 7.6 years (range, 0.7-18 years) and average weight of 26 kg (range, 6-77 kg). Thirty-six patients had general surgery, 57 patients urologic surgery, and 1 thoracic surgery. Overall average operative time was 189 min (range, 70-550 min), and average hospital stay was 6.4 days (range, 2-24 days). The procedures of 3 patients were converted. Median follow-up was 18 months (range, 0.5-43 months). Robotic surgical procedure had an extra cost of <euro>1934 compared to conventional open surgery.

CONCLUSIONS

Our experience was similar to the findings described in the literature for feasibility, security, and patient outcomes; we had an overall operative success rate of 97 %. Three main actors are concerned in the implementation of a robotic pediatric surgery program: surgeons and anesthetists, nurses, and the administration. The surgeon is at the starting point with motivation for minimally invasive surgery without laparoscopic constraints. We found that it was possible to implement a long-lasting robotic surgery program with comparable quality of care.

Laparoscopic versus robot-assisted Nissen fundoplication in an infant pig model

PURPOSE

Surgical robots are designed to facilitate dissection and suturing, although objective data on their superiority are lacking. This study compares conventional laparoscopic Nissen fundoplication (CLNF) to robot-assisted Nissen fundoplication (RANF) using computer-based workflow analysis in an infant pig model.

METHODS

CLNF and RANF were performed in 12 pigs. Surgical workflow was segmented into phases. Time required to perform specific actions was compared by t test. The quality of knot-tying was evaluated by a skill scoring system. Cardia yield pressure (CYP) was determined to test the efficacy of the fundoplications, and the incidence of complications was compared.

RESULTS

There was no difference in average times to complete the various phases, despite faster robotic knot-tying (p = 0.001). Suturing quality was superior in CLNF (p = 0.02). CYP increased similarly in both groups. Workflow-interrupting hemorrhage and pneumothorax occurred more frequently during CLNF (p = 0.040 and 0.044, respectively), while more sutures broke during RANF (p = 0.001).

CONCLUSION

The robot provides no clear temporal advantage compared to conventional laparoscopy for fundoplication, although suturing was faster in RANF. Fewer complications were noted using the robot. RANF and CLNF were equally efficient anti-reflux procedures. For robotic surgery to manifest its full potential, more complex operations may have to be evaluated.

Pediatric robotic surgery: early assessment

OBJECTIVES

This article reviews the evidence regarding the feasibility, safety, benefits, limitations, and costs of robotically assisted surgery in children, evaluates how the technology compares with other pediatric surgical techniques, and provides insights about the near and more-distant future of the technology.

METHODS

The peer-reviewed medical pediatric literature was searched for studies that provided evidence of the feasibility and safety of robotic surgery in children and for studies that compared pediatric robotic surgery with conventional laparoscopic surgery or open surgery.

RESULTS

A total of 8 case series and 5 studies comparing robotic surgery with open or conventional laparoscopic surgery met the selection criteria for review. A few small studies that focused on rare complex surgical procedures also were reviewed. All studies were designed to evaluate the feasibility and safety of robotic surgery in children. None of the studies was randomized, and some studies had a retrospective design. These studies demonstrated that a number of routine, robotically assisted, laparoscopic and thoracic procedures were feasible and safe when performed by surgeons experienced in the technique, although robotic surgery did not provide superior outcomes, compared with traditional laparoscopic and open surgery. The advantages of the robotic system were best seen in complex procedures that involved areas that were difficult to access and in procedures in which dissection of delicate, anatomic structures was required.

CONCLUSIONS

Robotic surgery is feasible and safe for a number of pediatric surgical procedures, but evidence that it offers better clinical outcomes than conventional open or laparoscopic techniques is lacking.

Pediatric robot-assisted laparoscopic excision of urachal cyst and bladder cuff

Urachal cysts are the most common urachal anomaly in the pediatric population. There is an increasing body of literature documenting successful management of urachal cysts using laparoscopic techniques. There may be an advantage, however, with the use of robot-assisted laparoscopy for reconstructive cases. We describe the techniques used for robot-assisted laparoscopic excision of a urachal cyst and bladder cuff with bladder repair in a female child. This approach is a safe and effective option for the minimally invasive management of pediatric urachal cysts.