Robot-assisted laparoendoscopic single-site pyeloplasty: technique using the da Vinci Si robotic platform

Comparison of robot-assisted single-port-plus-one pyeloplasty vs. laparoscopic single-port pyeloplasty in the treatment of ureteropelvic junction obstruction in children

Objective

To compare the efficacy of robot-assisted single-port-plus-one pyeloplasty (RSPY) and laparoscopic single-port pyeloplasty (LSPY) in the treatment of children with ureteropelvic junction obstruction (UPJO).

Methods

The clinical data of 47 children who underwent surgery for UPJO at the Department of the Pediatric Surgery of the Fujian Provincial Hospital from October 2020 to September 2022 were analyzed retrospectively. Of these 47 children, 27 received RSPY while 20 underwent LSPY. The baseline data, operation time, intraoperative anastomosis time, intraoperative blood loss, postoperative hospital stay, complications, total cost, preoperative and postoperative renal parenchymal thickness (PT), anteroposterior renal pelvis diameter (APD), and differential renal function (DRF) of the two groups were compared to evaluate the clinical efficacy of the two surgical methods.

Results

The results showed that both surgical techniques were successful and no patient transitioned to open surgery. There was no significant difference between the two groups in baseline data, intraoperative blood loss, complications, APD, and PT 6 months after surgery. There was also no significant difference in APD, PT, and DRF 12 months after surgery (all P > 0.05). Compared with the LSPY group, the RSPY group had shorter operation time [(153.04 ± 14.44) vs. (189.90 ± 32.59) min, t = -5.24, P < 0.05], less intraoperative anastomosis time [(68.81 ± 16.80) vs. (97.45 ± 11.99) min, t = -6.49, P < 0.05], shorter postoperative hospital stay [(5.96 ± 1.34) vs. (9.00 ± 1.33) d, t = -7.68, P < 0.05], but higher total cost [(57,390 ± 7,664) vs. (30,183 ± 4,219) yuan, t = 14.32, P < 0.05].

Conclusion

Compared with LSPY, RSPY achieves equivalent efficacy in the treatment of UPJO in children and has certain advantages by shortening the operation time, intraoperative anastomosis time, and postoperative hospital stay. However, its cost burden is heavy, and appropriate cases need to be selected for popularization and application.

Single-port technique evolution and current practice in urologic procedures

Different groups described the single-port surgery since its first report in laparoscopic procedures. However, the acceptance of this technique among urologists, even after the robotic approach, was reduced in the past years. Therefore, to overcome the challenges related to the single-port surgery, a new robotic platform named da Vinci SP was created with exclusive single port technology. We performed a non-systematic literature review regarding the single port technique in urologic surgeries since the first laparoscopic report until the da Vinci SP robotic platform. Three different periods were described (laparoscopy, robotic, and da Vinci SP), and we focused in our experience with this new single port robot. We selected different articles and summarized the information regarding the use of single-site surgery in laparoscopic procedures and the challenges of this approach. We also reported the experience of different groups using the single port robotic technique and some recent reports of the da Vinci SP approach. In our experience with this new console, we described some critical points related to our radical prostatectomy technique and the lessons learned during the introduction of this novel platform. Previous single-site procedures described some common challenges that limited the technique expansion. However, our experience with the da Vinci SP described feasible and safe procedures with acceptable intraoperative outcomes. The introduction of this platform is recent in the market, and the literature still lacks a high level of evidence describing the long-term outcomes of this new technology.

Pure single-site robot-assisted pyeloplasty with the da Vinci SP surgical system: Initial experience

Purpose

Laparoendoscopic single-site surgery (LESS) reduces the limited invasiveness of conventional laparoscopy while providing superior cosmetic results. However, LESS remains a challenging surgical technique, even in robotic surgery, primarily due to the lack of triangulation and limited instrument movement. The da Vinci SP surgical system (Intuitive Surgical) was recently introduced to overcome these limitations. We describe our initial experience with pure single-site robot-assisted pyeloplasty (RAP) for ureteropelvic junction obstruction (UPJO) using the da Vinci SP surgical system.

Materials and Methods

Three consecutive patients who were diagnosed with UPJO underwent RAP with the da Vinci SP surgical system from December 2018 to February 2019 at our institution. The surgical technique involved reproducing the steps of multi-port RAP. A 30-mm umbilical incision was made and the GelPOINT was inserted. The multichannel robotic port and the assistant's port were placed through the GelSeal cap. In all patients, Anderson–Hynes dismembered pyeloplasty was performed. The ureteral double J stent was inserted antegrade, and the drain was not placed.

Results

The procedures were successfully completed using a pure single-site approach. There was no need for additional port placement or conversion to laparoscopic or open surgery. Total operative time in the three patients was 139, 180, and 213 minutes, respectively. No intraoperative complications occurred, and blood loss was minimal. The postoperative course of all patients was uneventful with no complications greater than Clavien–Dindo grade I surgical complications.

Conclusions

Pure single-site RAP using the da Vinci SP surgical system is feasible and safe.

Robotic Laparoendoscopic Single Site: Pyeloplasty and Nephrectomy Chapter

Robotic laparoendoscopic single site (RLESS) for upper tract procedures is safe and feasible in the correctly selected patient. An ideal candidate is young, has a low body mass index, and is undergoing surgery for benign indications. For RLESS procedures, we utilize a GelPOINT^® access platform for "single-port" placement and ports are configured in a diamond shape. Five millimeter EndoWrist^® robotic instruments are placed under direct vision. Range of motion is increased by utilizing the chopstick technique. The surgeon must always be aware of the orientation of each instrument to prevent counter-springing associated with their crossing at the level of the abdominal wall. The robotic camera lens and instruments must be moved synchronously, given their coaxial orientation relative to each other. In this chapter, we describe our technique for two of the most common RLESS upper tract procedures: pyeloplasty and nephrectomy.

Current status of robotic single-port surgery

Robotic-assisted laparoscopic surgery in urology is an ever progressing field, and boundaries are constantly broken with the aid of new technology. Advancements in instrumentation have given birth to the era of robotic laparoendoscopic single-site technique (R-LESS). R-LESS however, has not gained widespread acceptance due to technical hurdles such as adequate triangulation, robotic arm clashing, decreased access for the bedside assistant, lack of wrist articulation, continued need for an axillary/accessory port, lack of robust retraction, and ergonomic discomfort. Many innovations have been explored to counter such limitations. We aim to give a brief overview of a history and development of R-LESS urologic surgery and outline the latest advancements in the realm of urologic R-LESS. By searching PubMed selectively for relevant articles, we concluded a literature review. We searched using the keywords: robotic laparoscopic single incision, robotic laparoendoscopic single-site, single incision robotic surgery, and R-LESS. We selected all relevant articles in that pertained to single-site robotic surgery in urology. We selected all relevant articles that pertained to single-site robotic surgery in urology in a table encompassed within this article. The development of the R-LESS procedures, instrumentations, and platforms has been an evolution in progress. Our results showed the history and evolution toward a purpose-built single-port robotic platform that addresses previous limitations to R-LESS. Even though previous studies have shown feasibility with R-LESS, the future of R-LESS depends on the availability of purpose-built robotic platforms. The larger concern is the demonstration of the definitive advantage of single-site over the conventional multiport surgery.

Robotic Single-port Surgery: Paving the Way for the Future

Adoption of robotic technology in urology has been widely popularized as it provides considerable advantages over standard techniques, including improved instrument dexterity, three-dimensional high-definition optics, and enhanced ergonomics. As a result, these features have facilitated the adaptation of robotics for laparoendoscopic single-site surgery (LESS) to overcome challenges with clashing, suturing, and intra-abdominal triangulation. Since the inception of robotic LESS by our institution in 2008,(1) many centers have gone on to study this approach in various urologic applications. Herein we discuss the evolution of robotic LESS access, instrumentation, and outcomes with special focus on up-and-coming technology.

Robotic-assisted laparoscopic approaches to the ureter: Pyeloplasty and ureteral reimplantation

INTRODUCTION AND OBJECTIVES

The benefits of robotic surgery when compared to standard laparoscopy have been well established, especially when it comes to reconstructive procedures. The application of robotic technology to laparoscopic pyeloplasty has reduced the steep learning curve associated with the procedure. Consequently, this has allowed surgeons who are less experienced with laparoscopy to offer this treatment to their patients, instead of referring them to centers of excellence. Robotic pyeloplasty has also proved useful for repairing secondary UPJO, a procedure which is considered extremely difficult using a conventional laparoscopic approach. Finally, the pursuit of scarless surgery has seen the development of laparoendoscopic single site (LESS) procedures. The application of robotics to LESS (R-LESS) has also reduced the difficulty in performing conventional LESS pyeloplasty. Herein we present a literature review with regards to robotic-assisted laparoscopic pyeloplasty. We also discuss the benefits of robotic surgery with regards to reconstruction of the lower urinary tract.

MATERIALS AND METHODS

A systematic literature review was performed using PubMed to identify relevant studies. There were no time restrictions applied to the search, but only studies in English were included. We utilized the following search terms: Ureteropelvic junction obstruction and laparoscopy; laparoscopic pyeloplasty; robotic pyeloplasty; robotic ureteric reimplantation; robotic ureteroneocystostomy; robotic boari flap; robotic psoas hitch.

RESULTS

There has been considerable experience in the literature with robotic pyeloplasty. Unfortunately, no prospective randomized studies have been conducted, however there are a number of meta analyses and systematic reviews. While there are no clear benefits when it comes to surgical and functional outcomes when compared to standard laparoscopic pyeloplasty, it is clear that robotics makes the operation easier to perform. There is also a benefit to the robotic approach when performing a redo-pyeloplasty. Robotic pyeloplasty has also been applied to the pediatric population, and there may be a benefit in older children while in very young patients, retroperitoneal open pyeloplasty is still the gold standard. In the field of single incision surgery R-LESS is technically easier to perform than conventional LESS. However, the design of the current robotic platform is not completely suited for this application, limiting its utility and often requiring a larger incision. Optimized R-LESS specific technology is awaited. What is clear, from a number of analyses, is that robotic pyeloplasty is considerably more expensive than the laparoscopic approach, largely due to costs of instrumentation and the capital expense of the robot. Until cheaper robotic technology is available, this technique will continue to be expensive, and a cost-benefit analysis must be undertaken by each hospital planning to undertake this surgery. Finally, the benefits of upper tract reconstruction apply equally to the lower tract although there is considerably less experience. However, there have been a number of studies demonstrating the technical feasibility of ureteral reimplantation.

CONCLUSIONS

Robotic-assisted laparoscopic pyeloplasty is gaining popularity, likely due to the shorter learning curve, greater surgeon comfort, and easier intracorporeal suturing. This has allowed more surgeons to perform the procedure, improving accessibility. Robotic technology is also beneficial in the field of LESS. Nevertheless, the procedure still is not as cost-effective as the conventional laparoscopic approach, and until more affordable robotic technology is available, it will not be universally offered.

Robotic single port surgery: Current status and future considerations

Introduction and Objectives:

It has been established that robotic-assisted laparoscopic surgery has several advantages when compared with standard laparoscopic surgery. Optics, ergonomics, dexterity and precision are all enhanced with the use of a robotic platform. For these reasons, it was postulated that the application of robotics to laparoendoscopic single-site surgery (LESS) could overcome some of the constraints seen with the conventional laparoscopic approach. Issues such as instrument clashing, inability to achieve effective triangulation for dissection and difficulties with intracorporeal suturing have limited the widespread adoption of conventional LESS. The application of robotics has eliminated many of the constraints experienced with conventional LESS; however, challenges still remain.

Materials and Methods:

A systematic literature review was performed using PubMed to identify relevant studies. There were no time restrictions applied to the search, but only studies in English were included. We used the following search terms: Robotic single site surgery, robotic single port surgery, robotic single incision surgery and robotic laparoendoscopic single site surgery.

Results:

A number of centers have published their experience with robotic-laparoendoscopic single-site surgery (R-LESS); however, no prospective studies exist. What is clear is that R-LESS minimizes several of the difficulties experienced with conventional LESS, including intracorporeal suturing and triangulation during dissection. Outcomes are comparable to standard robotic surgery, with a trend toward improved cosmesis and reduced pain. However, a significant advantage with regard to these two factors has yet to be demonstrated.

Conclusions:

R-LESS is technically feasible and the benefits of robotic surgery eliminate many of the challenges seen with conventional LESS. However, despite the advantages of the robotic platform, R-LESS is not free of challenges. Instrument clashing remains an issue due to the bulky profile of the current robotic system. Other issues include lack of space for the assistant at the bedside, inability to incorporate the 4^th robotic arm for retraction and difficulties with triangulation. Although solutions for some of these issues are currently under development, R-LESS is still very much in its infancy.