Endourology / Laparoscopy (1) - Part 1

92

ROBOTICALLY ASSISTED LAPAROSCOPIC ANTIREFLUX SURGERY IN CHILDREN

Craig PETERS and Joseph BORER*

Childrens Hospital Boston, Urology, Boston, USA - * Childrens Hospital, Urology, Boston, USA

PURPOSE: To assess the safety and efficacy of robotically assisted laparoscopic surgery for correction of vesicoureteral reflux (VUR) in children, we reviewed the results of our initial experience with this novel surgical technology.

MATERIAL AND METHODS: 24 patients underwent robotically assisted transperitoneal extravesical antireflux laparoscopic surgery for VUR using the DaVinci system. 3 ports were used with the camera in the umbilicus. The detrusor tunnel was created with electrocautery and the muscularis closed over the ureter with interrupted PDS sutures. No stents were left.

RESULTS: 22 girls and 2 boys (mean age 6.5 yrs, range 4.6 mos. to 11.3 yrs) underwent antireflux surgery (3 bilateral, 11 L 10 R). Mean operative time for the unilateral cases was 2.5 hours. Overnight catheter drainage was used in 18 patients, 2 nights in 2, and no catheter was left in 4. Patients were discharged after .25 to 3 days. Two patients had minor bladder leaks requiring catheter drainage. One child had post-operative bladder pain following bilateral surgery, which resolved with anticholinergic medication. With a mean of 19.5 months of follow-up, 22 have had imaging and are without upper tract dilation. 22 have had cystography, and 20 are free of reflux. Two patients have grade 2 reflux persisting and are being followed.

CONCLUSIONS: Our initial experience indicates that robotic assistance permits safe and effective laparoscopic antireflux surgery, and may be a useful option for routine antireflux surgery, with a possible reduction in peri-operative morbidity.

93

PEDIATRIC LAPAROSCOPIC PYELOPLASTY USING ROBOTIC ASSISTANCE

Craig PETERS, Stuart BAUER*, Bartley CILENTO* and Joseph BORER*

Childrens Hospital Boston, Urology, Boston, USA - * Childrens Hospital, Urology, Boston, USA

PURPOSE: The efficacy and efficiency of robotic assistance for pediatric laparoscopic pyeloplasty were assessed to determine its potential role.

MATERIAL AND METHODS: 30 children underwent laparoscopic pyeloplasty with robotic assistance (22 M, 8 F; mean age 8.2 yrs., range 0.25 - 19). Exposure was by medial reflection of the colon in 20, trans-mesenteric in 9 and retroperitoneal in 1. A stent was placed in 18, 10 had a wound drain only and 2 had no stent or drain. 30 open pyeloplasties were reviewed for length of stay (LOS) and cost.

RESULTS: There were no conversions or complications. Mean operative time was 3.5 hrs, with laparoscopic time averaging 2.5 hrs and was unaffected by laterality. Surgical experience influenced total operative time (p=0.02), as did use of a stent and exposure (p=0.005). Age positively correlated with time (p<0.0005; r2=.39). LOS was from 0.25 to 6 days. Compared to open pyeloplasty, operative times and total cost were 17% more but LOS was 27% less. With a mean 17 mos. of follow-up, 27 patients have been evaluated and 26 have satisfactory results with decreased dilation, reduced washout times and absence of pain. One patient required re-do pyeloplasty following retroperitoneal repair due to a missed crossing vessel.

CONCLUSIONS: This initial experience with laparoscopic pyeloplasty using robotic assistance shows its utility for minimally invasive reconstruction in children of all ages. The ability to perform enhanced anastomotic suturing should permit more rapid acquisition of the necessary skills than has been possible with conventional laparoscopic pyeloplasty.

94

ROBOTICALLY ASSISTED RETROPERITONEOSCOPIC PYELOPLASTY: MID-TERM OF 50 CASES WITH THE DA VINCI SURGICAL SYSTEM ®

Lars Henning OLSEN and Troels MUNCH JOERGENSEN*

Aarhus University Hospital- Skejby-, Urology - Division of Paediatric Urology, Aarhus, DENMARK - * Aarhus University Hospital-Skejby-, Urology, Division of Paediatric Urology, Aarhus, DENMARK

PURPOSE: To assess our experience with 50 retroperitoneoscopic pyeloplasties with the Da Vinci Surgical system, the largest series published so far.

MATERIAL AND METHODS: Fifty-two retroperitoneoscopic robotically-assisted pyeloplasties were performed in 50 children (median age 4.3 ys (2.0-16.2) 2 bilateral) from March 2002 until November 2004. The indications were pain, infections, decreasing differential function on MAG3 renography or a large hydronefrosis with an AP diameter of > 5o mm. . The catheter was removed 4-6 weeks after the primary procedure. The patients were followed with Ultrasound and MAG3 renography 3 and 9-12 months postoperatively. Data were prospectively recorded in a database.

RESULTS: The median operating time (skin-to-skin) was 155 minutes (76-230). The median postoperative hospital stay was 1 day (1-3). There were no peroperative complications. One patient was converted to open operation due to a large hydronephrosis and a distally placed UPJ which could not be reached by the system. Two patients were readmitted the 3rd and the 5th postoperative day due to occlusion of the JJ catheter by a blood clot and treated with a nephrostomy for few days. One patient without a JJ catheter was readmitted with similar symptoms and treated with a nephrostomy. In 3 patients the JJ catheter was found in the lower ureter and had to be removed with a Dormia basket. On follow-up (median 22 months (1-30) 3 patients had to be re-operated due to recurrent symptoms and/or decreasing differential function on MAG3 renography. One of these patients had an overlooked aberrant vessel, the two others a ‘kinking’ ureter. None of them had a re-stenosis.

CONCLUSIONS: Robotically-assisted retroperitoneoscopic pyeloplasty has proved to be a feasible procedure. The results are comparable with our own results and those of others with standard laparoscopic instruments. The operative time is shorter with major improvements for the laparoscopic surgeon. The system makes the procedure easier for less trained laparoscopic surgeons and is an major advantage for the ergonomics in laparoscopic surgery.

Read Endourology / Laparoscopy (1) Selected Abstracts - Part 2

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