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.

[Failures of endoscopic treatment of vesico-ureteric reflux in children using Macroplastique]. / Echecs du traitement endoscopique des reflux vésico-urétéraux (RVU) de l'enfant par injection de Macroplastique.

INTRODUCTION: Macroplastique has been used since 1993 for the endoscopic treatment of vesico-ureteric reflux in children with a failure rate per injected ureteric unit of 21%. The objective of this study was to analyse these failures on the basis of endoscopic findings on injection, ultrasound data at 2 months post-endoscopy and operative findings during the secondary reimplantation. MATERIAL AND METHODS: The authors retrospectively reviewed cases of failure of Macroplastique treatment from September 1993 to December 2002. Only children undergoing subsequent surgical reimplantation were included in the study: 60 cases (57 girls, 3 boys). Another 68 patients also presented recurrence of reflux, but are currently asymptomatic and have not been reoperated. Twenty five patients (42%) initially presented unilateral vesico-ureteric reflux: bilateral injection was performed in 17 of these cases because of the anatomical findings on endoscopy. In 92% of cases, the refluxing ureteric orifice appeared to be abnormal (in terms of position, appearance and the submucosal course of the ureter). RESULTS: Eleven children (18%) presented symptomatic or asymptomatic urinary tract infection before the first clinical and radiological review at 2 months. On the first ultrasound examination, the implant was visualized in the bladder wall in 71% of cases. At reimplantation, the bladder mucosa was inflammatory in 56 patients (94%). The ureteric orifice remained gaping in 38% of cases and the implant appeared to be modified (migration, decreased volume) in 35% of cases. CONCLUSION: Failures of endoscopic treatment by Macroplastique can be due to persistence of pre-existing ureteric anatomical lesions (poor indication, technical error or difficulty) or modification of the injected product. Bladder inflammation and therefore previous or post-endoscopy urinary tract infections may also play a role.

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.

[Endoscopic treatment of vesicoureteric reflux (VUR) in children: results of 9 years of use of Macroplastique (polydimethylsiloxane)]. / Traitement endoscopique des reflux vésico-urétéraux (RVU) de l'enfant: résultats de 9 ans d'utilisation du Macroplastique (polydiméthylsiloxane).

OBJECTIVE: Since 1993, the authors have used a Macroplastique (polydimethylsiloxane) implant for the endoscopic treatment of vesicoureteric reflux (VUR) in children instead of Teflon (polytetrafluoroethylene). They report their results after 9 years of use of Macroplastique and analyse their failures. MATERIAL AND METHODS: 477 children with 669 refluxing ureters, classified as grade I reflux in 96 cases (14%), grade II reflux in 435 cases (65%), grade III reflux in 125 cases (19%), and grade IV reflux in 13 cases (2%), were treated at Tours University Hospital by the same surgeon, by injection of 0.1 to 0.5 ml (mean: 0.3 ml) of Macroplastique. 189 cases of unilateral reflux (66%) required a bilateral procedure on the basis of the endoscopic findings. The efficacy of treatment was evaluated on the absence of clinical and bacteriological signs of urinary tract infection and the absence of reflux on cystography during the study period. RESULTS: 354 of the 477 children (74%) and 514 of the 669 refluxing ureters (77%), including 167 cases of bilateral VUR (65%) and 180 cases of unilateral VUR (35%) were cured. A significant difference was observed between the cure rate for bilateral reflux and unilateral reflux (p<0.05). The failure rate in cases of grade I and II reflux was significantly higher than in grade III and IV (p<0.05). The development of de novo contralateral reflux was not statistically related to unilateral or bilateral injection for the treatment of unilateral reflux. CONCLUSION: The authors believe that the failure rate for grade I and II reflux could be explained by the concomitant presence of detrusor-sphincter dyssynergia that was not systematically investigated preoperatively and by the fact that endoscopic correction of anatomical lesions gives better results in the case of probably more malformative grade III and IV reflux.

[Urethroplasty and separation of the corpora cavernosa for hypospadias repair]. / Spongioplastie et "déjantage" des corps caverneux. Intérêt dans la correction des hypospadias.

Hypospadias is a frequent malformation and its treatment is not devoid of complications, particularly fistulas. The authors describe the department's surgical technique (modified Duplay technique). Urethroplasty is no longer performed by simple approximation of the urethral plate without dissection. The inferior surface of corpora cavernosa is exposed as far as the lateral border and as far as the summit in the glans, allowing tension-free suture of urethral tissues with a lengthening effect of this intermediate plane. This completes correction of chordee and especially "bucket-handle" glans and protects the reconstructed urethra and proximal urethra. The risk of fistula is therefore reduced (2 cases out of 51). This technical modification can be used to treat all forms of distal hypospadias (glanular, glanulo-preputial, and anterior penile). It has also been used for several cases of more severe hypospadias. These good results must be confirmed in a larger series of patients.