Robot-assisted ureteroureterostomy in pediatric patients: current perspectives

The efficacy analysis of robotic versus laparoscopic ipsilateral uretero-ureterostomy for upper urinary tract duplications in pediatric population

OBJECTIVE

To review and compare robot-assisted ipsilateral ureteroureterostomy (RALUU) and laparoscopic ipsilateral uretero-ureterostomy (LUU) in terms of efficacy and outcomes.

METHODS

Clinical data of 65 children with complete renal ureteral duplication deformity admitted to the First Affiliated Hospital of Zhengzhou University from January 2015 to December 2022 were collected. Among these, 42 patients underwent laparoscopic ureteroureterostomy (LUU), designated as the LUU group, while 23 patients received robot-assisted laparoscopic ureteroureterostomy (RALUU), designated as the RALUU group. We compared the two groups regarding surgical duration, intraoperative blood loss, postoperative drainage duration, length of hospital stay, changes in anterior-posterior diameter (APD) of the affected renal pelvis pre- and postoperatively, changes in ureteral diameter, and alterations in renal function.

RESULTS

The postoperative drainage duration (Z = 2.375, P = 0.024) and length of hospital stay (t = 2.142, P = 0.038) were shorter in the RALUU group compared to the LUU group, with statistically significant differences. However, there were no statistically significant differences in surgical duration (t = - 1.465, P = 0.153) and intraoperative blood loss (Z = 1.679, P = 0.097) between the two groups. Complications occurred in three patients in the LUU group (two cases of anastomotic stricture and one case of stump syndrome), while no long-term complications were reported in the RALUU group, with no significant difference between the groups (χ2 = 0.482, P = 0.488). Both groups exhibited a tendency for improvement in APD, ureteral diameter (UD), and differential renal function (DRF) pre- and postoperatively. However, further analysis revealed that changes in APD (ΔAPD, t = - 1.132, P = 0.284), DRF (ΔDRF, Z = 1.865, P = 0.073), and UD (ΔUD, t = 1.562, P = 0.064) did not show statistically significant differences between the two groups.

CONCLUSION

Both RALUU and LUU are safe and effective treatments for children with complete renal ureteral duplication anomalies. Compared to LUU, RALUU is associated with shorter postoperative drainage duration and hospital stay.

Robot-assisted laparoscopic ipsilateral ureteroureterostomy for duplex kidneys in children: preliminary single-center experience

Objective

This study evaluates the efficacy and safety of robot-assisted laparoscopic ipsilateral ureteroureterostomy (RAL-IUU) in treating children with duplex kidney ureteral malformations by detailing our early single-center experience.

Materials and methods

We conducted a retrospective analysis of clinical data from 14 children with complete duplex kidney ureteral malformations treated with RAL-IUU at our institution from December 2021 to January 2024. Clinical data included patient demographics, surgical details, and postoperative outcomes.

Results

The operation time averaged 128.71 ± 22.35 min in 14 cases, intraoperative blood loss was 7.57 ± 2.77 ml, drainage tube placement lasted for 3.14 ± 0.66 days, and hospital stay averaged 4.79 ± 0.70 days. Stent placement lasted 43.58 ± 6.33 days. Notable changes were observed in the upper moiety anterior-posterior diameter (APD) before and after surgery (23.84 ± 8.05 mm vs. 6.71 ± 2.20 mm, P < 0.001), diameter at the widest part of the upper moiety ureter (15.58 ± 6.07 mm vs. 4.61 ± 0.78 mm, P < 0.001), and split renal function of the upper moiety (12.28 ± 3.04% vs. 16.50 ± 2.75%, P < 0.001). Postoperative follow-up ranged from 6 to 18 months; during the period with a D-J stent, one case developed a urinary tract infection, one case had recurrent gross hematuria, and another child exhibited significant urinary irritative symptoms (frequency), with an abdominal plain film revealing that the D-J tube had descended completely into the bladder, and symptoms disappeared after the removal of the D-J tube. During the follow-up period post-D-J tube removal, none of the 14 children experienced a urinary tract infection again during the follow up period, urinary incontinence ceased.

Conclusion

RAL-IUU provides an excellent surgical field and operating space, precise suturing, and minimal surgical trauma. Postoperatively, there is a reduction in renal pelvis and ureteral hydronephrosis, recovery of split renal function, and minimal complications all with rapid recovery. RAL-IUU is a safe and feasible treatment option for children with complete duplex kidneys.

A review of robotic-assisted laparoscopic partial nephrectomy in the management of renal duplication anomalies

Open and purely laparoscopic partial nephrectomy or heminephrectomy has been the standard management for renal duplication anomalies for symptomatic children with non-functional renal moieties. While robotic-assisted laparoscopic partial nephrectomy (RALPN) has been established as a safe and feasible option for the management of renal duplex anomalies, there remains a paucity of data on this topic. The aim of this study is to comprehensively review all available outcomes data and update the use of emerging technologies in robotic surgery which continue to make RALPN a viable and advantageous option in the management of renal duplex anomalies.

Pediatric robotic surgery: issues in management-expert consensus from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP)

BACKGROUND

Pediatric robotic-assisted surgeries have increased in recent years; however, guidance documents are still lacking. This study aimed to develop evidence-based recommendations, or best practice statements when evidence is lacking or inadequate, to assist surgical teams internationally.

METHODS

A joint consensus taskforce of anesthesiologists and surgeons from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP) have identified critical areas and reviewed the available evidence. The taskforce comprised 21 experts representing the fields of anesthesia (n = 11) and surgery (n = 10) from clinical centers performing pediatric robotic surgery in the Italian cities of Ancona, Bologna, Milan, Naples, Padua, Pavia, Perugia, Rome, Siena, and Verona. Between December 2020 and September 2021, three meetings, two Delphi rounds, and a final consensus conference took place.

RESULTS

During the first planning meeting, the panel agreed on the specific objectives, the definitions to apply, and precise methodology. The project was structured into three subtopics: (i) preoperative patient assessment and preparation; (ii) intraoperative management (surgical and anesthesiologic); and (iii) postoperative procedures. Within these phases, the panel agreed to address a total of 18 relevant areas, which spanned preoperative patient assessment and patient selection, anesthesiology, critical care medicine, respiratory care, prevention of postoperative nausea and vomiting, and pain management.

CONCLUSION

Collaboration among surgeons and anesthesiologists will be increasingly important for achieving safe and effective RAS procedures. These recommendations will provide a review for those who already have relevant experience and should be particularly useful for those starting a new program.

Robotic ureteral reimplantation and uretero-ureterostomy treating the ureterovesical junction pathologies in children: technical considerations and preliminary results

Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR) and robotic ureteroureterostomy (RUU) are two mini-invasive surgical techniques that have begun to be performed in pediatric urology in recent years. RALUR has been employed especially for VUR treatment, while RUU is considered principally in case of complex doubled ureteral systems. Our aim is to discuss the safety and feasibility of these approaches in children, focusing on technical considerations and supporting their use in different anomalies and pathologies of the ureterovesical junction. We retrospectively collected data about 58 patients who underwent 44 dismembered RALUR (D-RALUR), 28 non-dismembered RALUR (ND-RALUR) and 5 RUU between May 2020 and December 2021. Indications for surgery were primary or secondary vesicoureteral reflux, megaureter, secondary UVJ obstructions, complicated doubled ureteral systems. Mean age was 3.5 years (range 0.6-12.9) and mean weight 17.1 (range 7.2-80). No intraoperative complications occurred nor conversion to open approach were reported. Major postoperative complications were reported in 11.7% of cases with a higher incidence for ND-RALUR. Mean hospital stay was 2.14 days (range 1-8). Success rate at the short-term follow-up was 91.9% for D-RALUR, 96.3% for ND-RALUR and 100% for RUU. RALUR and RUU are two feasible and safe procedures to perform in children. RALUR represents the most required and adequate technique in the treatment of UVJ pathologies, however, in selected cases RUU could represent an effective alternative that has to be considered.

A single-center study of two types of upper kidney preservation surgery for complete duplicated kidney in children

OBJECTIVE

The objectives of this study were to compare the efficacy, advantages, and disadvantages of insertable ureteral reimplantation (UC group) and ureteral end-to-side anastomosis (UU group) in the treatment of duplicated kidney and summarize the clinical experience in its diagnosis and treatment.

METHODS

The current retrospective study enrolled 20 cases with duplicated kidney in Anhui Provincial Children's Hospital from April 2016 to June 2021, including 11 in the UC group and 9 in the UU group. There were 8 boys and 12 girls, with 12 on the left side and 8 on the right side. Meanwhile, there were three cases with urinary tract infection and nine with urinary incontinence. The rest of them were found by B ultrasound during physical examination. The median age of these patients was 33.5 months. Later, preoperative and postoperative renal pelvis separation, ureteral dilation, operation time, and drainage tube indwelling time were compared between the two groups.

RESULTS

There were statistically significant differences in operation time (282 ± 50.55 vs. 176 ± 61.92, P = 0.03), drainage time (9.36 ± 5.00 vs. 5.33 ± 1.22, P = 0.02), and hospital stay (22.18 ± 5.40 vs. 14.78 ± 5.33, P = 0.007) between the two groups. In addition, the degree of hydronephrosis (UC: 1.86 ± 0.93 vs. 1.08 ± 0.77, P = 0.00; UU: 1.8 ± 0.95 vs. 0.89 ± 0.60, P = 0.02) and ureteral dilatation (UC: 1.57 ± 0.30 vs. 0.72 ± 0.22, P = 0.00; UU: 1.47 ± 0.50 vs. 0.88 ± 0.22, P = 0.001) were statistically different between the two groups before and after surgery.

CONCLUSION

Compared with the UC method, the UU method has the advantages of less trauma, faster recovery, and fewer complications. Double J tube or ureter stent placement is beneficial for finding and protecting the lower ureter intraoperatively, without increasing the difficulty in operation, which can also prevent anastomosis or ureteral orifice stenosis.

Anesthetic Implications of Robotic-Assisted Surgery in Pediatric Patients

The novel technology of robotic-assisted surgery (RAS) has been utilized in children for the past two decades with several potential clinical benefits including reduction of postoperative pain, shortened hospital length of stay, and improved cosmetic outcomes. While associated costs and the limitations regarding instruments for smaller pediatric patients remain relevant issues, surgeon comfort related to ergonomic design in combination with enhanced three-dimensional high-fidelity imaging and tissue handling compared to traditional minimally invasive approached may offer improved surgical and postoperative outcomes. Given that the demand for this innovative technology will likely continue to expand in the field of pediatric surgery, pediatric anesthesiologists will be called upon to provide anesthetic care to patients exposed to this novel surgical technology with its unique features, intraoperative requirements, and potential complications. The current manuscript provides a narrative review of robotic-assisted surgery and discusses important anesthetic considerations and potential complications of these techniques.

Transureteroureterostomy in children: a retrospective study

Transureteroureterostomy (TUU) is a urinary reconstructive procedure seldom used but has a role when conventional reconstructive techniques are not possible. However, the concern is whether it places the opposite, non-diseased ureter and kidney at risk. Hence a retrospective study was conducted to evaluate indications, methods, and outcomes of transureteroureterostomy in children. The study included seven children who underwent TUU between January 2011 and December 2015. The mean age of the study group was 4.5 ± 2.9 years. Six (86%) patients were males. Two patients had primary bladder diverticulum, two posterior urethral valves, two cases of vesico-ureteric reflux, and one had a persistent urogenital sinus. All patients presented with recurrent urinary tract infections. Three (43%) patients had bladder outlet obstruction. Four (57%) patients underwent left to right TUU with right ureteric reimplantation. Two (29%) patients underwent an additional procedure. No complications were found. The key to a good outcome in TUU is case selection. Surgical technique plays a very important role in ensuring good long-term outcome without compromising the normal moiety.

Robot-assisted ipsilateral ureteroureterostomy in a duplex system utilizing intraoperative flexible ureteroscopy

Iatrogenic injury to the ureter during pelvic surgery is an uncommon but well-documented complication. Accurate identification of the ureter during pelvic surgery is made far more complex in the presence of a duplex or ectopic system, an anomaly occurring in up to 2% of the population. In this article we present a technique for robot-assisted ipsilateral ureteroureterostomy for treatment of iatrogenic injury of a lower pole moiety ureter in a complete duplex system.

Patient with duplex ureter injury underwent robot assisted laparoscopic common sheath ureteral reimplantation single docking: Case report

Ureteral injury is common complication that need comprehensive understanding of ureteral injury management from minimal invasive intervention to ureteral reimplant in both early and late presentation. However, ureteral injury in duplex system rarely reported in literature. Here we are sharing our techniques and challenging in a patient who had a duplex ureteral injury with late presentation underwent robot assisted ureteral reimplantation.