Robotic Surgery in Pediatric Oncology: Lessons Learned from the First 100 Tumors-A Nationwide Experience.

BACKGROUND: While robotics has become commonplace in adult oncology, it remains rare in pediatric oncology due to the rarity of childhood cancers. We present the results of a large nationwide experience with robotic oncology, with the aim of providing practical and feasible guidelines for child selection. METHODS: This was a prospective analysis performed over a period of 4 years. Treatment was delivered according to the Société Internationale d'Oncologie Pédiatrique/International Society of Paediatric Oncology Europe Neuroblastoma Group (SIOP/SIOPEN) protocols. Indications were approved by a certified tumor board. RESULTS: Overall, 100 tumors were resected during 93 procedures (abdomen, 67%; thorax, 17%; pelvis, 10%; retroperitoneum, 6%) in 89 children (56 girls). The median age at surgery was 8.2 years (range 3.6-13); 19 children (21%) harbored germinal genetic alterations predisposing to cancer. No intraoperative tumor ruptures occurred. Seven conversions (8%) to an open approach were performed. Neuroblastic tumors (n = 31) comprised the main group (18 neuroblastomas, 4 ganglioneuroblastomas, 9 ganglioneuromas) and renal tumors comprised the second largest group (n = 24, including 20 Wilms' tumors). The remaining 45 tumors included neuroendocrine (n = 12), adrenal (n = 9), germ-cell (n = 7), pancreatic (n = 4), thymic (n = 4), inflammatory myofibroblastic (n = 4), and different rare tumors (n = 5). Overall, 51 tumors were malignant, 2 were borderline, and 47 were benign. The median hospital stay was 3 days (2-4), and five postoperative complications occurred within the first 30 days. During a median follow-up of 2.4 years, one child (Wilms' tumor) presented with pleural recurrence. One girl with Wilms' tumor died of central nervous system metastasis. CONCLUSIONS: Robotic surgery for pediatric tumors is a safe option in highly selected cases. Indications should be discussed by tumor boards to avoid widespread and uncontrolled application.

Current perspectives in robot-assisted surgery.

From classical surgery to robot-assisted surgery (RAS), there has been a long way allowed by the improvements achieved in minimally invasive surgery (MIS). The last three decades have witnessed a prodigious development of MIS, and especially in the field of laparoscopic pediatric surgery but there are several limitations in the use of conventional laparoscopic surgery and RAS was developed to relieve these drawbacks. This new technology enables today the performance of a wide variety of procedures in children with a minimally invasive approach. As for all new technologies, an objective evaluation is essential with the need to respond to several questions: is the technology feasible?, is the technology safe?, is the technology efficient?, does it bring about benefits compared with current technology?, what are the procedures derived from most benefits of robotic assistance?, how to assume the transition from open surgery to minimally invasive access for RAS? In the first part of this article, some details are provided about technical concerns. Then, the implementation process with its organization, pitfalls, successes, and issues from human resources and financial standpoints is described. The learning curve is also analyzed, and a special focus on small children weighing less than 15 kg is developed. Finally, the concept of evaluation of this emerging technology is evocated and financial concerns are developed.

Partial nephrectomy for small children: Robot-assisted versus open surgery.

OBJECTIVES: To compare the outcomes of robot-assisted heminephrectomy for duplex kidney in children with those of open heminephrectomy. METHODS: The present retrospective multicentric analysis reviewed the records of robot-assisted versus open heminephrectomy carried out for duplex kidney in children from 2007 to 2014. Demographic data, weight, surgical time, hospital stay, complications and outcome were recorded. Follow up was based on a clinical review, renal sonography and dimercaptosuccinic acid renal scintigraphy. RESULTS: A total of 15 patients underwent robot-assisted heminephrectomy, and 13 patients underwent retroperitoneal heminephrectomy by open approach. All patients weighed <15 kg. The mean age at the time of surgery was 20.2 months (range 7-39 months) in the robotic group, and 18.4 months (range 6-41 months) in the open group. The mean hospital stay was statistically longer for the open surgery group (6.3 days, range 5-8 days vs 3.4 days, range 1-7 days; P < 0.001). Regarding postoperative pain control, total morphine equivalent intake was statistically greater for the open group (0.52 mg/kg/day vs 1.08 mg/kg/day; P < 0.001). No patient lost the remaining healthy moiety. There was no significant difference in terms of operating time, complication rate or renal outcomes. CONCLUSIONS: Robot-assisted heminephrectomy in small children seems to offer comparable renal outcomes with those of its standard open surgery counterpart. Specific technical adjustments are necessary, which typically increase the set-up time.

A comparison of robotic surgery in children weighing above and below 15.0 kg: size does not affect surgery success.

BACKGROUND: Initial results in pediatric surgery are encouraging, particularly in the field of pediatric urology. However, there is limited experience with its application in infants and neonates. The aim of this study was to compare the feasibility and safety of robotic-assisted surgery in two populations of children, one weighing less and one weighing more than 15.0 kg. METHODS: A multicentric study was performed comparing the success of robotic-assisted surgery in patients who weighed less than 15.0 kg (group A) to patients heavier than 15.0 kg (group B), with a total of 178 procedures performed between January 2008 and December 2012. Data concerning the perioperative and intraoperative periods were prospectively collected and retrospectively analyzed. RESULTS: The success of robotic-assisted surgery was compared between group A (62 patients, 11.1 kg) and group B (116 patients, 30.2 kg), with a mean follow-up of 37 months (16-75 months). The conversion rate was superior for group A (5 vs. 2%) and involved three neonatal thoracic procedures. Focusing on three common procedures for both groups (pyeloplasty, partial nephrectomy, and fundoplication), the amount of time for set up was longer for group A (p < 0.05). We found no statistical differences in the mean total operative time and length of hospital stay. The postoperative follow-up revealed similar results for both groups. CONCLUSIONS: Cautious adjustments in the patient positioning and trocar placement were necessary in a subset of this pediatric population. For these three particular procedures, with the exception of the longer set up time, the results between the two groups were comparable. These data support the feasibility of robotic-assisted surgery for small children, despite the lack of dedicated instruments.

How to successfully implement a robotic pediatric surgery program: lessons learned after 96 procedures.

BACKGROUND: Both our teams were the first to implement pediatric robotic surgery in France. The aim of this study was to define the key points we brought to light so other pediatric teams that want to set up a robotic surgery program will benefit. METHODS: We reviewed the medical records of all children who underwent robotic surgery between Nov 2007 and June 2011 in both departments, including patient data, installation and changes, operative time, hospital stay, intraoperative complications, and postoperative outcome. The department's internal organization, the organization within the hospital complex, and cost were evaluated. RESULTS: A total of 96 procedures were evaluated. There were 38 girls and 56 boys with average age at surgery of 7.6 years (range, 0.7-18 years) and average weight of 26 kg (range, 6-77 kg). Thirty-six patients had general surgery, 57 patients urologic surgery, and 1 thoracic surgery. Overall average operative time was 189 min (range, 70-550 min), and average hospital stay was 6.4 days (range, 2-24 days). The procedures of 3 patients were converted. Median follow-up was 18 months (range, 0.5-43 months). Robotic surgical procedure had an extra cost of 1934 compared to conventional open surgery. CONCLUSIONS: Our experience was similar to the findings described in the literature for feasibility, security, and patient outcomes; we had an overall operative success rate of 97 %. Three main actors are concerned in the implementation of a robotic pediatric surgery program: surgeons and anesthetists, nurses, and the administration. The surgeon is at the starting point with motivation for minimally invasive surgery without laparoscopic constraints. We found that it was possible to implement a long-lasting robotic surgery program with comparable quality of care.

Comparison of the Learning Curve for Robot-Assisted Laparoscopic Pyeloplasty Between Senior and Junior Surgeons.

Introduction: The widespread use of robotic surgery has provided surgeons a high-quality and alternative method to perform pyeloplasty. Indeed, robot-assisted technology has made it a lot easier to obtain the advanced technical skills required to perform this procedure. The learning curve (LC) reflects the increase in learning as a function of experience. Robot-assisted laparoscopic pyeloplasty (RALP) represents a well-standardized and reproducible procedure with an LC that allows reliable results to readily be obtained. The aim of our study was to compare the RALP LC of senior versus junior surgeons. Materials and Methods: We reviewed all of the RALP procedures performed at three pediatric surgery centers between November 2007 and November 2018. Three senior surgeons and 4 junior surgeons performed the robotic procedures. Neither the senior nor the junior surgeons had previous experience with robotic surgery; they had experience with conventional laparoscopic procedures but not with laparoscopic pyeloplasty. The primary metric that we selected to evaluate competence acquisition was a composite outcome defined by a combination of operative time (OT), complications, and surgical success. The complications were rated according to the Clavien-Dindo classification expressed by a complication factor; surgical success was expressed as a success factor, and we used a cumulative sum (CUSUM) analysis to determine the LC. The CUSUM method, through its multioutcome approach, is a very effective way to evaluate LCs. Results: Between November 2007 and November 2018, 3 senior surgeons and 4 junior surgeons performed 88 RALP procedures. The included patients had a median age of 6.1 years (range 7 months-16 years). The median duration of follow-up was 6.4 years (range 14 months-12 years). The median OT was 198.86 minutes (range 106-335 minutes). By CUSUM analysis of the composite outcome, we found that despite the junior surgeons having performed fewer procedures than the senior surgeons, their LCs exhibited an earlier inflection point (Fig. 1) followed by a constant rate of improvement in proficiency, thus indicating a more rapid learning process. The median composite scores for the senior surgeons and the junior surgeons were 299 (range 210-370) and 193 (range 131-255), respectively, after seven procedures. Conclusion: Assuming proper exposure to robotics and an adequate case volume, we demonstrated that junior surgeons can readily achieve comparable levels of expertise compared with senior practitioners in the field of pediatric RALP. It can be assumed that the LC in robotic pyeloplasty is not only directly influenced by the individual surgical experience but also by the experience of the surgical team.

Robot-Assisted Laparoscopic Fundoplications in Pediatric Surgery: Experience Review.

INTRODUCTION: Laparoscopic fundoplicature for gastroesophageal reflux disease has become the gold standard because of the improvement of postoperative rehabilitation compared with the open procedure. The robot-assisted surgery has brought new advantages for the patient and the surgeon compared with laparoscopy. We studied this new approach and the learning curve. MATERIALS AND METHODS: Sixty robot-assisted fundoplicatures were performed in two university pediatric surgery centers. Data of the patients were recorded, including peroperative data (operation length and complications), postoperative recoveries, and clinical evolution. The learning curve was evaluated retrospectively and each variable was compared along this learning curve. RESULTS: We observed a flattening of the learning curve after the 20th case for one surgeon. The mean operative time decreased significantly to 80 ± 10 minutes after 20 cases. There were no conversions to an open procedure. A revision surgery was indicated for 4.7% of the patients by a surgical robot-assisted laparoscopic approach. CONCLUSION: The robotic system appears to add many advantages for surgical ergonomic procedures. There is a potential benefit in operating time with a short technical apprenticeship period. The setting up system is easy with a short docking time.

Laparoscopic one port appendectomy: Evaluation in pediatric surgery.

BACKGROUND: Appendectomy is a well-established surgical procedure in pediatric surgery used in the management of acute appendicitis. With the continuous advancement in the field of minimal invasive surgery, the recent focus is on single incision laparoscopic (SIL) surgery. SILA also goes further in order to decrease pain, improve recovery and enhance patient satisfaction. However, this approach is still not a well-established technique and not widely practiced, especially in pediatric surgery. METHODS: We prospectively recorded the data in our pediatric universitary hospital center since January, 01 2017 to July, 01 2017. Patients included in this study were randomized in two groups: SILA group (managed by one-port laparoscopy, n=40) and LA group (conventional laparoscopy using three trocars, n=40). RESULTS: The mean operative time for SILA was significantly lower. There were no postoperative complications in SILA group. If peritonitis was associated with appendicitis, the operative duration was not significantly different between each group. The duration in recovery room after surgery was significantly lower in SILA group. The morphine consumption was significantly lower for SILA group according to patient weight. SILA is less painful significantly than CLA for the first postoperative 6 h. After, even if SILA appears less painful, difference is not significant. The hospital length of stay was significantly higher in LA than SILA group CONCLUSIONS: SILA procedure for appendectomy appears to be safe and efficient for appendicitis management in children. This technique could be applied in routine as in emergency tome. TYPE OF STUDY: Prospective comparative study LEVEL OF EVIDENCE: II.

Polyurethane versus silicone port a cath: What's going on at removal?

BACKGROUND: Port-a-cath (PAC) is an essential device in the management of the patients of chronic illness, but despite theirs benefits there are many complications either at the time of insertion or at time of removal. Our aim of this study is to evaluate the fracture rate of the catheter at removal time in comparison with catheter type either polyurethane or silicone. METHODS: A retrospective monocentric study of all PACs which were removed at our university pediatric hospital between 1 January 2006 and 31 December 2016. Two groups were compared: polyurethane group and silicone group. RESULTS: Total of 216 central lines were removed, the mean age at the time of extraction was 9.7±4.9years and the mean time for both catheter was 2.7±1.6years, fracture occurred in 11 catheter of the polyurethane group (n=119), with no fracture of silicone group (n=86), in the polyurethane group, the risk of catheter fracture is significantly related to the duration of the PAC in place. CONCLUSION: We found that the polyurethane-based catheters are more vulnerable for rupture and retained fragment in the blood vessels, especially if left in place for long time, for this reason we have switched to silicone-based catheter and all catheters should be remove within duration maximal of 2years. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: Level II.

High Pressure Balloon Dilatation of Primary Obstructive Megaureter in Children: A Multicenter Study.

Aim of the Study: We described the initial experience of four referral centers in the treatment of primary obstructive megaureter (POM) in children, by high-pressure balloon dilatation (HPBD) of the ureterovesical junction with double JJ stenting. We managed a retrospective multicenter study to assess its effectiveness in long-term. Methods: We reviewed the medical records of all children who underwent HPBD for POM that require surgical treatment from May 2012 to December 2017 in four different institutions. The primary outcome measured was ureterohydronephrosis (UHN) and its degree of improvement after the procedure. Secondary outcomes were postoperative complications and resolution of preoperative symptomatology. Main Results: Forty-two ureters underwent HPBD for POM in 33 children, with a median age of 14.7 months - (range: 3 months -15 years). Ureterohydronephrosis improves in 86% of ureters after one endoscopic treatment. Three cases required a second HPBD. Four patients required surgical treatment for worsening of UHN after endoscopic treatment. The post-operative complication rate was 50% (21 ureters). In 13 cases (61%), they were related to double J stent. The median follow-up was 24 months (2 months -5 years) and all patients were symptom-free. Conclusion: We reported the first multicenter study and the largest series of children treated with HPBD, with an overall success rate of 92%. Endoscopic treatment can be a definitive treatment of POM since it avoided reimplantation in 90% of cases. Complications are mainly due to double J stent.

Laparoscopic Pyloromyotomy: A Study of the Learning Curve.

INTRODUCTION: Laparoscopic pyloromyotomy (LPM) is a minimally invasive surgical technique used in pyloric stenosis treatment. This technique is safe, effective, and does not show more complications than laparotomy. Nevertheless, this technique requires an acquisition period to be optimally applied. This study analyses the learning curve of LPM. MATERIALS AND METHODS: Seven surgeons were retrospectively evaluated on their 40 first LPM. Patient data were recorded, including peroperative data (operation length and complications) and postoperative recoveries (renutrition, vomiting, and complications). The learning curves were evaluated and each variable was compared with the different moments of the learning curve. RESULTS: The mean operative time is 25 ± 11 minutes. It significantly decreases with the learning curve (p < 0.01). Ten procedures were necessary to acquire the operative technics. However, postoperative complications with a necessary redo procedure appear after the 10th patient. There is no significant difference concerning long-term postoperative complications according to the learning curve and to surgeons. The best results are recorded after the 20th patients. Hospital length of stay also decreases significantly after the 10th procedure. The recorded postoperative vomiting is independent to the operative time as the ad libitum feedings recovery. CONCLUSION: The learning curve of LPM is cut into three stages. Only 10 cases are needed to acquire the gesture. Complications appear after this acquirement period.

Assessment of paediatric thoracic robotic surgery.

OBJECTIVES: Many studies have reported that robotic-assisted surgery is safe and feasible for paediatric cases. However, very few paediatric thoracic robotic cases have been described. The aim of this study was to share our preliminary experience with robot-assisted thoracic surgery (RATS). METHODS: We reviewed our first, consecutive thoracic robotic procedures between January 2008 and December 2013. Data describing the perioperative and intraoperative periods were prospectively collected in two surgical paediatric centres and then retrospectively analysed. Operation time, completion rate, length of hospitalization and postoperative complications were compared with thoracoscopic results in the literature. RESULTS: Eleven patients were operated on with the robot, and this included operations for oesophageal atresia (3), mediastinal cyst (4), diaphragmatic hernia (2), oesophagoplasty (1) and oesophageal myotomy (1). The mean age at surgery was 72 (range 0-204) months, and the mean weight was 24.4 (range 3.0-51.5) kg. Three of the operations were converted to thoracotomies. The total operation time was 190 (120-310) min, and the average length of hospital stay was 13 (3-35) days. RATS offers similar advantages to thoracoscopy for mediastinal cyst excision in patients weighing more than 20 kg. Appropriate patient positioning and trocar placement were necessary for neonatal patients and thereby resulted in longer preparation times. Despite cautious adjustments, technical feasibility was reduced for low-weight patients. CONCLUSIONS: These data support mediastinal cyst excision as a suitable indication for larger children. Currently, there is a lack of evidence that lower weight children, and particularly neonates, are good candidates for RATS.

Laparoscopic treatment of renal cancer in children: a multicentric study and review of oncologic and surgical complications.

OBJECTIVE: The aim was to report a multicentric study with a longer follow-up to evaluate the laparoscopic radical nephrectomy in children with renal cancer. MATERIAL AND METHODS: This was a retrospective multicentric study, from October 2005 to January 2012, of children who underwent a laparoscopic radical nephrectomy for small renal malignant tumors. RESULTS: Seventeen children were included in this study. Sixteen underwent chemotherapy before surgery according the SIOP (Société Internationale d'Oncologie Pédiatrique) protocol and one was treated by surgery only for a carcinoma. All except one could be treated by laparoscopy; the biggest tumoral size was 8 cm. The median hospital stay was 3 days (2-10). The pathologic examination showed 15 Wilms' tumors, one clear cell sarcoma and one TFE3 renal cell carcinoma. With a median follow-up of 42 months (range 12 and 77 months) after laparoscopic radical nephrectomy, 15 children had no oncological complications (port site or local recurrence, pulmonary metastasis) and one had a local recurrence without intraoperative tumoral rupture. The child with TFE3 renal cell carcinoma died 4 years after surgery from brain and lung metastases without local recurrence. No small bowel obstruction occurred. CONCLUSIONS: Radical nephrectomy in children for Wilms' tumor or other renal cancer can be safely performed laparoscopically and our indications can be summarized, for trained laparoscopic surgeons, by small tumors under about 8 cm diameter, especially without crossing the lateral edge of the vertebra on the CT scan at the time of surgery.