Review of robot-assisted laparoscopic surgery in management of infant congenital urology: Advances and limitations in utilization and learning.

As robotic-assisted (RAL) surgery expanded to treat pediatric congenital disease, infant anatomy and physiology posed unique challenges that prompted adaptations to the technology and surgical technique, which are compiled and reviewed in this manuscript. From the beginning, collaboration with anesthesia is critical for a safe, efficient case including placement of an endotracheal tube rather than a laryngeal mask (LMA) and placement of a nasogastric tube and/or rectal tube to relieve distended stomach or bowel, respectively. Furthermore, end-tidal CO2 (EtCO2 ) is important for monitoring and predicting the effects of pneumoperitoneum on caridiovascular physiology, incranial pressure, and risk of acidosis and hypercarbia. Positioning can further exacerbate these effects and affect intra-abdominal working space. For infant robotic pyeloplasty and heminephrectomy, a "beanbag" is commonly used for stabilization in the lateral decubitus position. We advise against the use of a "baby bump" because it brings the bowels and vasculature more anterior than expected. Pnuemoperitoneum pressure of 8-10 mmHg during port placement maximizes safety, but thereafter, the pneumoperitoneum pressure can be minimized to 6-8 mmHg during the procedure without compromising the visual field. Port sites should be marked after insufflation, followed by the open Hasson technique for peritoneal access and port placement under direct vision with intussusception of the trocars to avoid vascular or bowel injury. Additional tips can be obtained through this manuscript, immersive fellowships, and mini-fellowships. Ulitmately, infant robotic surgery has the potential to benefit many children but is presently limited by the lack of pediatric-specific robotic technology and its associated costs.

Pediatric robotic urologic procedures: Indications and outcomes.

Introduction: Robotic-assisted laparoscopic surgery (RALS) has revolutionized minimally invasive surgery in pediatric urology. The robotic platform allows surgeons to maintain the benefits of laparoscopic surgery while having enhanced three-dimensional view, dexterity, range of motion, and control of high-resolution cameras. In this review, we summarize the indications and recent outcomes for various pediatric urologic RALS procedures to illustrate the current state of robotics in pediatric urology. Methods: We systematically searched the PubMed and EMBASE databases. We extrapolated and summarized recent evidence on RALS in pediatric urology patients, with an emphasis on indications and outcomes, with regard to the following procedures and search terms: pyeloplasty, kidney stone surgery, partial nephrectomy, nephroureterectomy, ureteral reimplantation, appendico-vesicostomy, augmentation cystoplasty, bladder neck reconstruction, and Malone antegrade continence enema. Additional Medical Subject Headings terms used to augment the search included "Treatment Outcome" and "Robotic Surgical Procedures." Results: Increasing usage of RALS has shown many benefits in perioperative and postoperative outcomes. In addition, there is growing evidence that robotic procedures in pediatric urology result in similar or better surgical outcomes when compared to the standard of care. Conclusions: RALS has shown considerable effectiveness in pediatric urologic procedures and may achieve surgical outcomes comparable to the standard approaches of open or laparoscopic surgery. However, larger case series and prospective randomized controlled trials are still necessary to validate the reported outcomes, in addition to cost analyses and studies on the surgical learning curve. We believe that the continuous evolution of robotic platforms will allow for enhanced care and quality of life for pediatric urology patients.

Are there disparities in access to robot-assisted laparoscopic surgery among pediatric urology patients? US institutional experience.

OBJECTIVE: Literature suggests access to robotic surgery varies by race and payer status. We seek to investigate whether disparities exist in robot-assisted laparoscopic surgery among the pediatric urology population at our tertiary academic medical center and, if so, to find plausible reasons why. METHODS: Retrospective analysis identified patients who underwent open or robot-assisted laparoscopic surgery by a single surgeon at a tertiary care center between 2008 and 2019. Univariate and multivariate analyses determined the relationship of patient demographic and socioeconomic factors to procedure approach. RESULTS: Among 356 patients, race, age, American Society of Anesthesiologists status, and year of surgery were significant by univariate analysis. Insurance status was not significant (P = 0.066). Multivariate analysis indicated that age, American Society of Anesthesiologists status, and year of surgery were statistically significant (P < 0.001, P = 0.005, P < 0.001). By multivariate logistic regression, Black and Hispanic patient race were not significant with an odds ratio of 0.60 (0.35-1.02) (P = 0.061). In 60.2% of open cases, open approach selection was attributable to complex pathology, limitations of robotic approach, and surgeon's robot-assisted laparoscopic learning curve. CONCLUSIONS: Optimal procedure approach was determined by case complexity and surgeon's robot-assisted laparoscopic learning curve and was independent of patient race and payer status. This study did not find racial or socioeconomic disparities in robotic surgery within pediatric urology at our tertiary medical center, inconsistent with previous literature.

Robot-assisted laparoscopic pyeloplasty in infants and children: is it superior to conventional laparoscopy?

INTRODUCTION: Open pyeloplasty (OP) has been the first-line treatment for ureteropelvic junction obstruction (UPJO) since it was first described by Anderson and Hynes. The use of minimally invasive surgery (MIS) to treat UPJO in the pediatric population has increased in recent years, due to decreased morbidity and shorter recovery times. Recently, robot-assisted laparoscopic pyeloplasty (RALP) has seen a steady expansion. Unlike laparoscopic pyeloplasty (LP), RALP comes with a more manageable learning curve aided by specialized technological advantages such as high-resolution three-dimensional view, tremor filtration with motion scaling, and highly dexterous wrist-like instruments. With this review, we aim to highlight the trend toward robotic pyeloplasty over laparoscopy and current available evidence on outcomes. METHODS: We systematically searched the PubMed and EMBASE databases, and we critically reviewed the available literature on the use of laparoscopy and robotic technology in pediatric patients with UPJO. RESULTS: Overall, we selected 19 original articles and 5 meta-analyses. The available literature showed that the robotic approach to the UPJO allowed for decreased operative times, shorter length of hospital stay, lower complication rates, with success rates comparable to LP. Conflicting results persist regarding robotic platform and equipment costs. CONCLUSION: While laparoscopy requires advanced skills for complex reconstructive procedures, such as pyeloplasty, robot-assisted surgery offers the valuable potential of making MIS more accessible to these types of procedure. Robotic technology has contributed to shortening the learning curve by acting as a bridge between open and endoscopic approach. There is still a strong need for higher quality evidence in the form of prospective observational studies and clinical trials, as well as further cost-effectiveness analyses. As robotic surgical technology spreads, future systems will be developed, offering smaller and more flexible tools, allowing enhanced applications on pediatric patients.

Lessons learned from a single-surgeon series of paediatric robot-assisted laparoscopic urological procedures: predictors of high-grade postoperative complications.

OBJECTIVES: To describe postoperative complications after robot-assisted laparoscopic urological surgery in children, and identify potential predictors of these complications by analysing the outcomes of a large-volume single-surgeon experience. PATIENTS AND METHODS: We reviewed our institutional database to identify all robot-assisted laparoscopy (RAL) cases performed between December 2007 and December 2017. Patients were grouped into three cohorts based on the anatomical location of the procedure: upper urinary tract (kidney and renal pelvis); lower urinary tract (ureter); and lower urinary tract reconstruction with bowel (bladder reconstruction). A descriptive analysis of baseline characteristics, intra-operative variables and postoperative outcomes was carried out. All complications were graded using the Clavien-Dindo scale, and grouped based on type and time of occurrence (<30, 30-90, >90 days). Multivariable logistic regression analysis was performed to identify predictors of high-grade complications (Clavien-Dindo grade ≥ III). We also measured complication rates based on year of surgery and surgical caseload. RESULTS: Our database included a total of 326 patients, of whom 57% (n = 186) underwent upper urinary tract procedures, 30% (n = 97) ureteric procedures, and 13% bladder reconstruction. The median follow-up for each procedure was 13, 11 and 57 months, respectively. Of the total, 10 cases were converted to an open approach and excluded from further analysis. The most common types of complication in all groups were infections (urinary tract infections) and urinary complications (urine leaks and urolithiasis). Bladder reconstructive procedures, which require the use of bowel, presented the highest rate of high-grade complications (32%). Length of hospital stay (LOS; odds ratio [OR] 1.33, confidence interval [CI] 1.16-1.53), estimated blood loss (EBL) in surgery (OR 1.01, CI 1.002-1.019) and operating time (OR 1.004, CI 1.002-1.006) were all associated with increased odds of high-grade complications on multivariate analysis (P < 0.05). CONCLUSIONS: In this single-surgeon series, we have described the most commonly encountered complications after RAL in paediatric urology, finding rates similar to the complication rates reported in the current literature on other surgical approaches. In addition, LOS, operating time and EBL, which are probable surrogates of case complexity, were associated with increased odds of high-grade complications.

Setting up a pediatric robotic urology program: A USA institution experience.

Implementing a robotic urological surgery program requires institutional support, and necessitates a comprehensive, detail-oriented plan that accounts for training, oversight, cost and case volume. Given the prevalence of robotic surgery in adult urology, in many instances it might be feasible to implement a pediatric robotic urology program within the greater context of adult urology. This involves, from an institutional standpoint, proportional distribution of equipment cost and operating room time. However, the pediatric urology team primarily determines goals for volume expansion, operative case selection, resident training and surgical innovation within the specialty. In addition to the clinical model, a robust economic model that includes marketing must be present. This review specifically highlights these factors in relationship to establishing and maintaining a pediatric robotic urology program. In addition, we share our data involving robot use over the program's first nine years (December 2007-December 2016).

Multi-Institutional Review of Outcomes and Complications of Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation for Treatment of Primary Vesicoureteral Reflux in Children.

PURPOSE: Robot-assisted laparoscopic extravesical ureteral reimplantation has been proposed as a minimally invasive alternative to open ureteral reimplantation for correcting primary vesicoureteral reflux in children. However, in the current literature there are conflicting data regarding the safety and efficacy of this approach. Amid ongoing debate we analyzed outcomes and complications from this procedure in a large multi-institutional cohort. MATERIALS AND METHODS: We reviewed the records of children who underwent robot-assisted laparoscopic extravesical ureteral reimplantation at 9 academic centers from 2005 to 2014. Radiographic failure was defined as persistent vesicoureteral reflux on postoperative voiding cystourethrogram or radionuclide cystogram. Complications were graded using the Clavien-Dindo scale. RESULTS: A total of 260 patients (363 ureters) underwent robot-assisted laparoscopic extravesical ureteral reimplantation for primary vesicoureteral reflux during the study period. The cohort included 90 patients with either duplex ureter (42), failed endoscopic treatment (40) or concomitant diverticulectomy (8). Of the 280 ureters with postoperative voiding cystourethrogram or radionuclide cystogram available radiographic resolution was seen in 246 (87.9%). There were 25 complications overall (9.6%), with 7 grade 3 complications (2.7%) and no grade 4 or 5 complications. Four patients (3.9%) had transient urinary retention following bilateral reimplantation. CONCLUSIONS: Robot-assisted laparoscopic extravesical ureteral reimplantation has a low complication rate consistent with published series of open ureteral reimplantation. Radiographic success rates are approaching those of the open procedure but continue to fall short of the gold standard approach. These findings necessitate critical thinking regarding potential technique improvements and further prospective investigation into the efficacy of this procedure.

Robot-assisted laparoscopic pyeloplasty in the pediatric population: a review of technique, outcomes, complications, and special considerations in infants.

Ureteropelvic junction obstruction is a common condition encountered by the pediatric urologist, and treated with pyeloplasty when indicated. Recent technological advancements and a shift across all surgical fields to embrace minimally invasive surgery have led to increased utilization of minimally invasive pyeloplasty. Conventional laparoscopy is a reasonable choice, but its use is limited by the technical challenges of precise suturing in a confined space and the associated considerable learning curve. Robotic technology has simplified the minimally invasive approach to pyeloplasty, offering enhanced visualization and improved dexterity with a fairly short learning curve. As utilization of robotic pyeloplasty continues to increase, we sought to critically assess the literature on this approach. We begin with a review of the technical aspects of robot-assisted laparoscopic pyeloplasty including tips for surgical proficiency and patient safety. Outcomes and complications from the contemporary literature are reviewed, as well as special considerations in the pediatric population including infant pyeloplasty, cost concerns, training, and postoperative diversion/drainage.

Robot-assisted laparoscopic ureteric reimplantation: extravesical technique.

OBJECTIVES: To describe our standardised approach to performing robot-assisted extravesical ureteric reimplantation. PATIENTS AND METHODS: A total of 29 children, with high grade (III-V) vesico-ureteric reflux (VUR) underwent robot-assisted extravesical ureteric reimplantation between September 2010 and September 2013. Follow-up renal ultrasonography was performed at 1 month and 3 months and a voiding cysto-urethrogram (VCUG) was obtained at 4 months to assess VUR resolution. RESULTS: The mean (range) patient age at the time of surgery was 5.38 (3.0-10.0) years. Postoperative VCUG showed complete resolution of VUR in 32/40 ureters (80%). Of the remaining refluxing ureters, downgrading of VUR on VCUG was shown in 7/8 ureters (87.5%). The mean (range) length of hospital stay was 1.8 (1-3) days. CONCLUSIONS: In conclusion, robot-assisted extravesical ureteric reimplantation is technically feasible with acceptable resolution of VUR.

Does robot-assisted laparoscopic ileocystoplasty (RALI) reduce peritoneal adhesions compared with open surgery?

OBJECTIVES: To compare perioperative outcomes between open ileocystoplasty and robot-assisted laparoscopic ileocystoplasty (RALI) in a porcine model, as objective data comparing outcomes between these two approaches in children with neurogenic bladder are lacking. We specifically examined differences in postoperative peritoneal adhesion formation between the groups. MATERIALS AND METHODS: In all, 20 pigs were assigned to an open ileocystoplasty or RALI study arm. All the pigs underwent an initial urodynamic study (UDS). In the RALI arm, reconstructive steps were performed intracorporeally using a standard da Vinci(®) system. Postoperatively, variables including first stool, weight gain, and complications were recorded. After 42 days, the pigs underwent a final UDS followed by adhesion assessment. Intraperitoneal adhesions were quantified by a third-party 'blinded' surgeon according to previously described objective scoring systems. RESULTS: Preoperative variables including UDS were similar in both groups. Overall operating time was significantly shorter for open ileocystoplasty than for RALI (149 vs 287 min, P < 0.001, respectively). Postoperatively, all variables including time to first stool, weight gain, and urodynamic parameters were similar amongst the groups. Pigs in the open arm developed significantly more adhesions (P = 0.02) and adhesions with a higher complexity (P = 0.04). CONCLUSIONS: In this porcine model, RALI achieved similar functional outcomes as the open approach, but required longer procedural times. The number and complexity of surgical adhesions among the groups favoured the RALI cohort. This may be of clinical significance in the paediatric spina bifida population, who generally undergo multiple surgical procedures in their lifetime, with increased risk for development of adhesions and subsequent intestinal obstruction.

Pediatric robotic urologic surgery-2014.

We seek to provide a background of the current state of pediatric urologic surgery including a brief history, procedural outcomes, cost considerations, future directions, and the state of robotic surgery in India. Pediatric robotic urology has been shown to be safe and effective in cases ranging from pyeloplasty to bladder augmentation with continent urinary diversion. Complication rates are in line with other methods of performing the same procedures. The cost of robotic surgery continues to decrease, but setting up pediatric robotic urology programs can be costly in terms of both monetary investment and the training of robotic surgeons. The future directions of robot surgery include instrument and system refinements, augmented reality and haptics, and telesurgery. Given the large number of children in India, there is huge potential for growth of pediatric robotic urology in India. Pediatric robotic urologic surgery has been established as safe and effective, and it will be an important tool in the future of pediatric urologic surgery worldwide.

Outcomes of infants undergoing robot-assisted laparoscopic pyeloplasty compared to open repair.

PURPOSE: Robotic surgery has evolved from simple extirpative surgery to complex reconstructions even in infants. Data are lacking comparing surgical and direct costs to open approaches. We describe the feasibility, salient tips and outcomes of robot-assisted laparoscopic pyeloplasty compared to an open approach. MATERIALS AND METHODS: We evaluated patients undergoing open pyeloplasty or robot-assisted laparoscopic pyeloplasty. Ten patients in each group met inclusion criteria. RESULTS: Mean patient age was 3.31 months in the open group and 7.3 months in the robotic group (p=0.02). Postoperative outcomes including length of stay (2.2 vs 2.1 days), estimated blood loss (6.5 vs 7.6 ml), days to regular diet (1 vs 1.1) and days to Foley catheter removal (1.3 vs 1.3) were similar between the open and robotic groups. Total operating time (199 vs 242 minutes) was significantly longer in the robotic group. Postoperative improvement in hydronephrosis was identical in both groups. Direct costs, excluding amortization, robotic cost, maintenance and depreciation, were $4,410 in the open group and $4,979 in the robotic group (p=0.10). CONCLUSIONS: In our preliminary experience robotic pyeloplasty in infants is feasible and safe. The immediate outcomes are similar to those of an open approach. The robotic technique in infants currently has the benefits of improved esthetic appearance, improved pain control and similar direct costs compared to the traditional open approach.

Robotic assisted laparoscopic Mitrofanoff appendicovesicostomy (RALMA).

The area of robotic surgery has steadily changed the field of urology. This minimally invasive approach is proving itself as a practical option, even in the pediatric patient. Robotic surgery allows the surgeon to perform fine suturing and precise dissection under magnified vision, making it ideal for complex reconstructive urinary tract surgery. Mitrofanoff appendicovesicostomy allows for effective emptying of the bladder while maintaining continence in children that cannot otherwise perform urethral catheterizations. Initial reports and series are encouraging, and appear to be comparable to that of open appendicoveiscostomy. In this review, we examine the current literature regarding robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy in children, provide technical recommendations and compare the outcomes with published open series. As more parents seek minimally invasive options for their children and robotic technology continues to develop throughout more centers, robotic surgical applications will expand to even more complex reconstructions.

Robotic-assisted laparoscopic reconstructive surgery in the lower urinary tract.

Open surgery has long been the most common surgical approach for the correction of congenital anomalies of the lower urinary tract in children. With the continued development of minimally invasive surgery in adult urology, including endoscopic, conventional, and robot-assisted laparoscopic approaches, the indications for minimally invasive surgery have similarly expanded in the pediatric population. The most commonly performed robotic procedure in children has been pyeloplasty for ureteropelvic junction obstruction; the use of robotics in complex reconstructive surgery in the lower urinary tract has also been acceptable. In this review, we summarize recent viewpoints regarding robotic-assisted laparoscopic reconstructive surgeries in the lower urinary tract, such as ureteral reimplantation, appendicovesicostomy, and augmentation enterocystoplasty in the pediatric population, and critically summarize the current knowledge on outcomes in the literature. We also discuss our technique and the outcomes of robotic ureteral reimplantation. This review demonstrates that robotic-assisted laparoscopic reconstructive surgeries in the lower urinary tract are technically feasible and may achieve outcomes that are equalto those of open surgery, with reduced morbidity.

Urodynamic studies in spinal cord tethering.

INTRODUCTION: Tethered cord syndrome (TCS) is of particular interest to urologists through its effects on the function of the lower urinary tract. Tethering of the spinal cord can result in bladder dysfunction with multiple manifestations, clinically raging from urinary retention and detrusor under-activity to urinary incontinence, over-activity of the detrusor, and sphincter dysfunction. Goals of management include protecting renal function and preserving patient quality of life. METHODS: Evaluation of a TCS patient with urinary complaints begins with a thorough history and physical examination. Further characterization of urinary symptoms with a voiding diary provides vital information that helps to direct treatment while engaging the patient and family in the treatment plan. Urodynamic studies then provide key diagnostic data regarding bladder function, bladder outlet resistance, and urinary sphincter function. In the pediatric population, particular care must be paid to counseling patients and their families prior to the procedure to alleviate the often-considerable anxiety associated with an invasive procedure. CONCLUSION: The armamentarium for management of neurogenic bladder associated with TCS includes behavioral training, biofeedback therapy, medications, patient-performed procedures, and surgical intervention. The choice of intervention depends on the patient's symptoms, urodynamic findings, and patient and family preferences. The primary problem of TCS should be addressed first through detethering, and then the urological team can use progressively more aggressive therapies as necessary. Interpretation and treatment by a dedicated, specialized, multidisciplinary team that includes the pediatric urologist, pediatric neurosurgeon and dedicated nurse practitioner, is critical for successful treatment.

Robot-assisted pyeloplasty for ureteropelvic junction obstruction in renal anomalies.

The surgical video demonstrates the technical nuances of performing pyeloplasties on complex renal anomalies, including duplex, horseshoe, malrotated, and ectopic kidneys. The video also highlights the anatomic relationships of the affected kidney for proper port placement and positioning during the procedure.

The LUAA Gundeti Technique for Bilateral Robotic Ureteral Reimplantation: Lessons Learned over a Decade for Optimal (Resolution, Urinary Retention, and Perioperative Complications) Trifecta Outcomes.

Background: Ureteral reimplantation is the gold standard treatment for high-grade vesicoureteral reflux (VUR) in pediatric patients. Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) using the LUAA technique has emerged as a viable alternative to traditional open and laparoscopic surgical correction. Objective: To evaluate the outcomes, reflux resolution, urinary retention, and complications associated with bilateral RALUR-EV for primary VUR using the LUAA Gundeti technique in pediatric patients. Design setting and participants: A retrospective study was conducted at a single academic center, involving 34 consecutive pediatric patients who underwent RALUR-EV for bilateral VUR management between December 2008 and December 2022. The study included only patients who were evaluated with postoperative voiding cystourethrogram (VCUG). Surgical procedure: The LUAA extravesical ureteral reimplantation technique was performed, involving the identification and mobilization of the ureter, creation of a peritoneal window, dissection close to the neurovascular bundle, Y dissection at the ureterovesical junction, detrusorotomy, detrusorrhaphy with advential inclusion, and apical alignment suture. Measurements: The primary outcome was radiographic resolution of VUR on VCUG. The secondary outcomes included urinary retention and Clavien-Dindo grade III complications. Results and limitations: The overall radiographic resolution rate was 85.2%, with success rates of 76.7%, 75%, and 96.7% across the three distinct patient cohorts. The overall Clavien-Dindo grade III complication rate was 5.8%, and transient urinary retention was 8.8%. Resolution of urinary retention occurred within 7-28 d. The study's limitations include the small sample size, single-center design, and retrospective nature. Conclusions: The LUAA technique demonstrates sustainable outcomes for VUR resolution with a low incidence of transient urinary retention and complications. A thorough understanding of pelvic anatomy is essential for successful dissection and minimization of the risk of complications. Further studies are needed to evaluate the effectiveness of different approaches in reducing the incidence of transient urinary retention following bilateral extravesical reimplantation. Patient summary: In this study, we examined the results of the Gundeti LUAA surgical technique for treating primary vesicoureteral reflux in children. We identified various essential modifications that increase the likelihood of achieving favorable outcomes.

Postoperative hydronephrosis following ureteral reimplantation: Clinical significance and importance of surgical technique and experience.

BACKGROUND: Though common, postoperative hydronephrosis (POHN) following ureteroneocystostomy raises concern for an underlying obstruction. We aimed to determine the clinical significance of POHN following open (OUR) or robotic (RALUR) ureteral reimplantation. METHODS: We retrospectively reviewed pediatric patients who underwent ureteral reimplantation for vesicoureteral reflux (VUR) from 2008 to 2019 by a single surgeon. Baseline characteristics, operative outcomes, and trends in POHN were assessed. POHN was defined as new onset hydronephrosis or exacerbation of pre existing hydronephrosis. Renal ultrasounds were performed 1, 4, and 12 months postoperatively. Voiding cystourethrograms were performed 4 months postoperatively. Surgical experience for RALUR cases was defined as number of ureters operated over time. RESULTS: Altogether, 93 patients (127 ureters) underwent RALUR and 19 patients (26 ureters) underwent OUR. POHN was found in 27.6% and 30.8% of ureters after RALUR and OUR, respectively. Rate and time to POHN resolution for RALUR (91.4%, 112 days) and OUR (75%, 211 days) were statistically similar. Odds of POHN after RALUR were directly related with preoperative VUR grade (Range OR: 2.82[2.26-3.52]) and surgical experience (Range OR: 8.88[7.16-11.02]). Surgical experience was inversely related with odds of VUR recurrence (Range OR: 0.41[0.32-0.54]). Rates of VUR resolution were comparable for OUR and RALUR patients. No patient required additional intervention for POHN. CONCLUSIONS: Incidence and resolution rate of POHN after OUR and RALUR were similar. Higher VUR grades were associated with increased odds of POHN after RALUR. Increasing RALUR experience improved VUR resolution rate but increased odds of POHN. Surgical success rates were similar for RALUR and OUR. LEVEL OF EVIDENCE: II.