Robotic surgery in infants and children: an argument for smaller and fewer incisions.

PURPOSE: Robotic-assisted laparoscopic (RAL) surgery has gained momentum in pediatric urology. Technological adaptations such as the development of 5 mm instruments have led to robotic procedures being performed on younger children and those having smaller body habitus, with improved cosmesis. However, concerns have been raised regarding decreased intra-abdominal working space and the absence of monopolar curved scissors (hot endoshears®) when using 5 mm instruments. The aim of this study is to examine the overall experience at a single pediatric urology center using 5 mm instruments with no planned additional assistant ports during common robotic procedures. We hypothesized this approach is safe and feasible for a variety of pediatric urologic reconstructive procedures. METHODS: We retrospectively reviewed all major robotic procedures entered into an IRB approved data registry. The analysis was performed only for procedures in which 5 mm instruments were used exclusively with hook diathermy. Procedures that utilized 8 mm instrumentation were excluded from the study. Data were abstracted according to patient age, weight and robotic surgery performed. Outcomes included post-operative complications (Clavien-Dindo classification), operative time, operative blood loss, need for assistant port placement and conversion rates to open or pure laparoscopic surgery. RESULTS: From 2012 to 2016, 220 consecutive pediatric RAL urological surgical cases were performed on 201 patients. These comprised pyeloplasty (n = 102) 46.4%, ureteral reimplants (n = 84) 38.2% and ipsilateral ureteroureterostomy (n = 34) 15.5%. Median age at surgery was 4 years (3 months to 18 years). There were no conversions to open or laparoscopic surgery. Placement of an additional Assist port was documented in seven cases. Severe (Clavien grade 4) complications occurred in two patients requiring ICU admission: one for sepsis and one ventilator-dependent patient having increased work of breathing post-op. Intra-operative blood loss was minimal ( < 50 ml) in 97% of cases. Patients ≤ 1 year of age comprised 28.6% of the study population. Univariate analysis revealed no association between age and occurrence of complications (p = 0.957) CONCLUSIONS: This study represents one of the largest series of consecutive RAL surgery using 5 mm instruments in pediatric urology. Acceptable complication rates, OR times and blood loss were achieved using this technique. We conclude that the use of 5 mm instruments gives excellent operative outcomes in pediatric reconstructive procedures.

Use of Ultrasound in Pediatric Renal Stone Diagnosis and Surgery.

Pediatric urolithiasis is on the rise globally and incidence rates have risen by 6-10% annually over the past couple of decades. Given the increasing incidence, high likelihood of recurrence, and long life expectancy of children, the use of ionizing radiation in the diagnosis, management, and follow up of pediatric urolithiasis has been scrutinized recently and many institutions and organizations have emphasized the use of non-ionizing imaging modality such as ultrasound. This review examines the use of ultrasound in the diagnosis and treatment of pediatric urolithiasis. Specifically, the role of ultrasound in shockwave lithotripsy, percutaneous nephrolithotomy, and, more recently, ureteroscopy will be examined.

Upper or lower tract approach for duplex anomalies? A bi-institutional comparative analysis of robot-assisted approaches.

Optimal management of duplication anomalies may include an upper or lower tract surgical approach. In the contemporary era, the robot-assisted laparoscopic heminephrectomy (RALHN) and robot-assisted laparoscopic ipsilateral ureteroureterostomy (RALIUU) are viable interventions predicated on clinical, institutional and surgeon preferences. We present a multi-institutional comparative analysis aiming to compare the outcomes of RALHN and RALIUU to see if either of the approaches confers an advantage over the other in treating duplex renal anomalies needing intervention. We completed a retrospective review of consecutive children undergoing RALIUU at Hospital A and RALHN at Hospital B from January 2009 to March 2017. The primary outcome was 'surgical success' defined by the resolution of clinical symptoms, improved radiological parameters, and no unplanned subsequent interventions till the time of study completion. Secondary outcomes included operative parameters, complications, and subsequent urinary infections. There were 39 RALIUU and 28 RALHN. Baseline demographic and clinical parameters across two cohorts were similar. The primary outcome of 'surgical success' was 100% across both cohorts. There were no major surgical complications, and the incidence of postoperative urinary tract infection was minimal and similar for both groups. Operative time favored RALHN; blood loss and analgesic requirements were minimal in both cohorts. Both RALIUU and RALHN are definitive surgical interventions in children with complex duplex moieties, delivering satisfactory surgical outcomes with a low complication profile and marginal differences in the postoperative patient outcomes. This pilot bi-institutional study provides the basis for a larger collaboration to further define optimal techniques, standardize surgical care pathways, and interrogate long-term outcomes.

Laparoscopic inguinal hernia repair by modified peritoneal leaflet closure: Description and initial results in children.

INTRODUCTION: Inguinal hernias are common in infants and children. While the gold standard for hernia repair in the pediatric period has been via an open inguinal incision with dissection and high ligation of the hernia sac, over the past two decades laparoscopic herniorrhaphy has increased in popularity. The advantages of laparoscopy include decreased post-operative pain, improved cosmetic results, ability to easily assess the contralateral side for an open internal inguinal ring, and decreased risk of metachronous hernias. Herein, we describe a modified laparoscopic herniorrhaphy using a peritoneal leaflet closure and report our operative experience with intermediate-term results. METHODS: We retrospectively reviewed our IRB-approved registry for all children who underwent initial laparoscopic herniorrhaphy at our tertiary care center over a 2.5-year period. All surgeries were performed by a single surgeon using a technique we have termed the peritoneal leaflet closure. This technique involves incising the peritoneum circumferentially around the open internal ring and developing peritoneal leaflets which are then closed together over the ring with a running non-absorbable barbed stitch (Figure). Intraoperative findings and complications, operative times, and post-operative complications were reviewed for all children. RESULTS: A total of 50 initial laparoscopic hernia repairs (4 bilateral, 42 unilateral) were performed in 46 children (43 boys, 3 girls) at a median age of 5.9 years (range 0.5-16.7). Median operative time was 73 min (range 48-138) for unilateral and 106 min (range 104-135) for bilateral herniorrhaphy. No patient had an intraoperative complication. Two children (4%) had contralateral open rings discovered at time of surgery and underwent unplanned bilateral laparoscopic hernia repair. All patients went home on the same day as the procedure and three children (6%) had minor post-operative complaints (umbilical bulge, thigh pain, and urine holding) that all self-resolved. Thirty-nine children had follow-up data available. Intermediate-term complications occurred in two children (5%): one boy developed a contralateral hydrocele (despite a closed ring at surgery) and one boy had a hernia recurrence that required open repair. Overall, operative success with the modified peritoneal leaflet closure technique was therefore 97% (38 of 39 children with follow-up). All 37 boys who followed up had bilateral descended testes of normal size and consistency. CONCLUSIONS: Laparoscopic herniorrhaphy using a peritoneal leaflet closure technique is safe and effective when used in infants and children to close an indirect hernia (i.e. patent processus vaginalis). No intraoperative complications occurred in this cohort and success rate was 97%.

Prospective multicenter study on robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV): Outcomes and complications.

BACKGROUND: Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is a minimally invasive alternative to open surgery. We have previously reported retrospective outcomes from our study group, and herein provide an updated prospective analysis with a focus on success rate, surgical technique, and complications among surgeons who have overcome the initial learning curve. OBJECTIVE: To assess the safety and efficacy of RALUR-EV in children, among experienced surgeons. DESIGN AND METHODS: We reviewed our prospective database of children undergoing RALUR-EV by pediatric urologists at eight academic centers from 2015 to 2017. Radiographic success was defined as absence of vesicoureteral reflux (VUR) on postoperative voiding cystourethrogram. Complications were graded using the Clavien scale. Univariate regression analysis was performed to assess for association among various patient and technical factors and radiographic failure. RESULTS: In total, 143 patients were treated with RALUR-EV for primary VUR (87 unilateral, 56 bilateral; 199 ureters). The majority of ureters (73.4%) had grade III or higher VUR preoperatively. Radiographic resolution was present in 93.8% of ureters, as shown in the summary table. Ureteral complications occurred in five ureters (2.5%) with mean follow-up of 7.4 months (SD 4.0). Transient urinary retention occurred in four patients following bilateral procedure (7.1%) and in no patients after unilateral. On univariate analysis, there were no patient or technical factors associated with increased odds of radiographic failure. DISCUSSION: We report a radiographic success rate of 93.8% overall, and 94.1% among children with grades III-V VUR. In contemporary series, alternate management options such as endoscopic injection and open UR have reported radiographic success rates of 90% and 93.5% respectively. We were unable to identify specific patient or technical factors that influenced outcomes, although immeasurable factors such as tissue handling and intraoperative decision-making could not be assessed. Ureteral complications requiring operative intervention were rare and occurred with the same incidence reported in a large open series. Limitations include lack of long-term follow-up and absence of radiographic follow-up on a subset of patients. CONCLUSIONS: Radiographic resolution of VUR following RALUR is on par with contemporary open series, and the incidence of ureteral complications is low. RALUR should be considered as one of several viable options for management of VUR in children.

Laparoscopic repair of a rare acquired abdominal intercostal hernia.

INTRODUCTION: An acquired abdominal intercostal hernia (AIH) is a very rare and sporadically reported entity. Most cases of AIH are secondary to major trauma and the treatment of choice is surgical repair. PRESENTATION OF CASE: We present the case of a 58-year-old man who presented with a painless intercostal swelling, which started after previous penetrating trauma to the same area. Radiological assessment was done with CT scan and the hernia was repaired with a laparoscopic approach using mesh. DISCUSSION: AIH is a rare entity and trauma has an integral role in the pathophysiology. Surgical repair is the treatment of choice, however, due to the paucity of cases, there is no established method of choice for such repair. We present the first reported case in the Caribbean, which was repaired with the laparoscopic approach. CONCLUSION: Although AIH is a rare condition, the pathophysiology seems relatively straightforward and the use of CT scan is recommended to confirm the diagnosis. The laparoscopic approach, with all its established benefits, appears to be a safe and feasible option in its management.