Minimally invasive versus open ileal ureter with ileocystoplasty: comparative outcomes and 5-year experience.

PURPOSE: To present the experience of ileal ureter with ileocystoplasty (IUC), and compare the outcomes of IUC in minimally invasive procedures to open procedures. PATIENTS AND METHODS: From December 2017 to April 2023, twenty patients underwent IUC in open or minimally invasive (including laparoscopic and robotic) procedures. The baseline characteristics, perioperative data and follow-up outcomes were collected. Success was defined as relief of clinical symptoms, stable postoperative serum creatine and absence of radiographic obstruction. The perioperative and follow-up outcomes of open procedures and minimally invasive procedures were compared. RESULTS: The etiology included pelvic irradiation (14/20), urinary tuberculosis (3/20) and surgical injury (3/20). Bilateral ureter strictures were repaired in 15 cases. The surgeries conducted consisted of open procedures in 9 patients and minimally invasive procedures in 11 patients. Compared to open procedures, minimally invasive surgeries had less median estimated blood loss (EBL) (100 ml vs. 300 min, p = 0.010) and shorter postoperative hospitalization (27 d vs. 13 d, p = 0.004). Two patients in the open group experienced grade 3 complications (sigmoid fistula and acute cholecystitis in one patient, and pulmonary embolism in another patient). Over a median follow-up period of 20.1 months, the median bladder functional capacity was 300 ml, with a 100% success rate of IUC. CONCLUSION: IUC is feasible in both open and minimally invasive procedures, with acceptable complications and a high success rate. Minimally invasive procedures can have less EBL and shorter postoperative hospitalization than open procedure. However, prospective studies with larger groups and longer follow-up are needed.

Surgical Option in the Management of a Giant Vesical Calculus Post Augmentation Cystoplasty.

We describe a rare instance of enormous, calcified stone development in an enlarged urinary bladder. The patient was a 24-year-old female suffering from the development of vesical calculus as a result of complicated bladder augmentation. She had a small bladder capacity and had undergone augmentation ileocystoplasty in childhood. The abdomen was examined using X-ray and computerized tomography, which revealed a significantly huge urinary bladder stone. An open cystolithotomy was performed and a giant vesicle calculus was extracted along with another small stone. Although stone development is a typical side effect following augmented bladder, it may be avoided with frequent bladder irrigation and attentive aftercare.

Purely robotic ileocystoplasty in children: why not? First case in Spain. / Ampliación vesical pediátrica mediante abordaje robótico puro: ¿por qué no? Primer caso en España.

INTRODUCTION: We present the first case of pediatric ileocystoplasty using a purely robotic approach in Spain. CASE REPORT: 12-year-old male with neurogenic bladder of low capacity and high pressures. After failure of conservative treatment, bladder augmentation with ileum patch was decided upon. Surgery was carried out using a purely robotic approach with 4 robotic and 2 accessory ports. Surgery duration was 380 minutes in total, without intraoperative complications. He was discharged 2 weeks after cystographic control. During 32-months follow-up, he has remained continent. DISCUSSION: The minimal invasion, surgical precision and ergonomics made the robotic approach an optimal option for complex surgical techniques. Given the little availability of the robot and the low pediatric volume, its standardization is a challenge. Our accumulated experience is consistent with the current literature and shows promising surgical and esthetic results. We hope this case report will contribute to the divulgation and progressive introduction of robotic surgery in our daily lives.

INTRODUCCION: Presentamos el primer caso de abordaje robótico pediátrico puro en España. CASO CLINICO: Varón de 12 años con vejiga neurógena de escasa capacidad y altas presiones sin respuesta al tratamiento conservador, abogando por una ileocistoplastia de aumento. Se lleva a cabo un abordaje robótico puro con 4 puertos robóticos y 2 accesorios, de 380 minutos de duración total sin complicaciones intraoperatorias. Es dado de alta a las 2 semanas previo control cistográfico. Tras 32 meses de seguimiento continúa continente. COMENTARIOS: La mínima invasión, mayor precisión y ergonomía del abordaje robótico, hacen de éste una opción óptima para técnicas quirúrgicas complejas. Dada la difícil disponibilidad del robot y el escaso volumen pediátrico, resulta un reto su normalización en este campo. Nuestra experiencia coincide con la literatura, mostrando resultados quirúrgicos y estéticos prometedores. Esperamos este reporte contribuya a la difusión e introducción progresiva de la cirugía robótica en nuestra rutina.

Aggressive Bladder Tumour Following Clam Ileocystoplasty: A Rare Long-Term Complication.

Overactive bladder syndrome (OAB) is a common, chronic, complex, often under-reported and under-treated condition with a significant impact on quality of life. It poses a high burden on healthcare systems. Clam ileocystoplasty is an invasive procedure typically reserved for the treatment of severe refractory cases. Malignant transformation in the area of anastomosis remains a rare but real, life-threatening risk in the patient group and requires active life-long surveillance and follow-up. We report the case of a 51-year-old woman who presented with recurrent urinary tract infections and non-visible haematuria 30 years after clam ileocystoplasty for urge incontinence. Imaging revealed an anterior bladder tumour with hepatic metastases. On multiple occasions, she was unfit for any invasive surgical sampling options to obtain tissue samples to allow for treatment planning, and was provided with best supportive care. The disease rapidly progressed to death within 10 weeks of presentation. This case buttresses the need for informed consent regarding the risks, including malignant transformation several years after the procedure, and the necessity for lifelong follow-up and surveillance cystoscopy, with frequency tailored to individual patient risk assessment.

[Analysis of surgical complications of reconstructive plastic surgery according to the ClavienDindo classification].

INTRODUCTION: The systematization of surgical complications has long been a serious problem since different types of surgical procedures have specific complications, in addition to general consequences. Created in 1992 and improved in 2004, the Clavien-Dindo classification was successfully validated in surgical centers in different countries and recognized as an important tool for the qualitative assessment of surgical complications. AIM: To improve reconstructive procedures by systematizing complications based on the ClavienDindo classification. MATERIALS AND METHODS: The results of substitution ileocystoplasty in 95 patients with contracted bladder due to tuberculosis and other diseases are presented. In 50 (52.6%) cases, the length of the bowel segment was 30-35 cm (group 1, main), while in 45 patients (47.4%) a segment of 45-60 cm was chosen (group 2, control). RESULTS: Early complications of grade II developed in 11 (22.0%) patients in the group 1 and in 13 (28.9%) in group 2, while grade III in 5 (10.0%) and 6 (13.3%) cases, respectively. Complications of IIIb grade were seen among patients of the main group in 9 (18.0%) cases compared to 12 (26.7%) in the control group. Severe complications of IVa and IVb grades were documented with the same frequency in both groups, in one case each. Complications of V grade (death) were recorded only in the group 2. Late complications were registered in 63 out of 94 patients. In group 1, there were 26 complications (16 somatic and 10 surgical), while in group 2, a total of 37 complications (24 somatic and 13 surgical) were seen, which indicates a significant higher rate in the control group (p<0.05). In group 1, transurethral resection of urethral-enteric anastomosis and ureteral reimplantation were performed less frequently than in group 2, while transurethral resection of the prostate was done with the same frequency. At the same time, percutaneous nephrostomy was required more often in the group 1 (6% vs. 4.5% in the group 2). After intestinal cystoplasty with a shortened fragment of the ileum, the voiding volume was significantly lower but corresponded to the physiological value (more than 150 ml). In this group, there was sufficient capacity of neobladder with a minimum amount of residual urine, effective emptying, satisfactory urinary continence, and low intraluminal pressure, which contributes to the protection of kidneys from reservoir-ureteral-pelvic reflux. The serum chloride level after surgery was 106.2+/-0.4 in the group 1 compared to 109.7+/-0.3 in the group 2, while base excess was -0.93+/-0.3 and -3.4+/-0.65, respectively (p<0.05). CONCLUSION: Early serious postoperative complications according to Clavien-Dindo were registered with approximately the same frequency in both groups, while late complications developed significantly more often in the group 2. The urodynamic parameters of a neobladder formed from ileum segment of 30-35 cm are satisfactory. In addition, a decrease in the length of the intestinal segment prevents the development of hyperchloremic metabolic acidosis.

Long-term results of augmentation ileocystoplasty in spinal cord injury patients.

INTRODUCTION: The aim of this article was to report the long-term results of increased ileocystoplasty in 58 patients with spinal cord injury (SCI) with an impact on overall renal function and quality of life. In a representative number of patients, where we followed individual subjects for more than 20 years, we wanted to determine their quality of life and preservation of renal function after surgery. MATERIAL AND METHODS: After unsuccessful conservative therapy of urinary incontinence, increased ileocystoplasty was performed. In addition to biochemical analysis, intravenous urography (IVU) was performed preoperatively (urography and/or ultrasound assessment of the upper urinary tract) and urodynamic tests were performed in all patients preoperatively. RESULTS: After a follow-up of patients within the group (>20 years), 2 patients reported being incontinent. The median elapsed time of action was 20 (13-24) years. Vesical capacity increased in all cases postoperatively when the median vesical capacity was 420.0 (387.5-460.0) ml (p <0.001). Long-term complications included use of bladder chambers, kidney stones and urosepsis. Creatinine clearance confirmed satisfactory renal function after the elapsed time period from surgery. CONCLUSIONS: The results confirmed that augmentation ileocystoplasty had excellent long-term outcomes in the definitive therapy of refractory neurogenic detrusor overactivity in patients with SCI.

Complication profile of augmentation cystoplasty in contemporary paediatric urology: a 20-year review.

BACKGROUND: The aim of this study was to describe the complication profile of augmentation cystoplasty in contemporary paediatric urology as well as its effect on bladder metrics. METHODS: Consecutive operative cases were retrospectively reviewed at a single institution over 20 years (1999-2019). Short- and long-term outcomes and complications following augmentation cystoplasty were defined. RESULTS: Of the 71 operative cases; the most common underlying diagnoses were neurogenic bladder (34%), exstrophy-epispadias complex (30%) and posterior urethral valves (23%). The most common tissue-type utilized was ileal (58%) and ureteric (30%). Peri-operative urine leak affected nine (13%) children but reservoir perforations were less common (4%). Mean end-of-study detrusor pressure improved significantly following bladder augmentation (38-17 cmH2 O, P < 0.001). Bladder capacity improved significantly (67-89%, P = 0.041). The median follow-up was 4.5 years (interquartile range: 1.9-10 years). Bladder urolithiasis affected 13 (18%) patients, and symptomatic urinary tract infections 36 (51%) patients. Formation of a continent catheterisable channel contributed a number of complications relating predominantly to stenosis (50%). Repeat augmentation cystoplasty was necessary in three (4%) cases. CONCLUSION: Augmentation cystoplasty is a surgical intervention that improves bladder metrics. Given the potential complications, careful patient selection and appropriate pre-operative counselling are essential. Furthermore, pro-active post-operative management and transitional care are vital in the surgical care of children following augmentation cystoplasty.

Case report: The theory of post-ileocystoplasty spherical configuration in patients with low-capacity bladder.

INTRODUCTION: Bladder augmentation can be performed by detubularization of the small or large intestine. A large capacity bladder is necessary to avoid frequent urination; thus, the ileal sac must be able to store the maximum volume of urine with relatively low pressure and the shortest length of the intestine. The acceptable pressure capacity should always be under ureteric pressure to avoid back pressure and kidney damage. Large capacity at low pressure is referred to as good compliance. Desirable preparations for augmentation, which is the use of the shortest length of the intestine, reduce the chance of diarrhea and vitamin deficiency and retain the intestines which may be required for augmentation. AIM: Clinical and urodynamic evaluation of the recent postoperative condition of the patient who underwent ileocystoplasty, confirmed by the theory of detubularization (spherical) configuration. CASE PRESENTATION: Patient with complaints of frequent urination and small amount of urine. Ultrasound examination showed low volume bladder capacity and bilateral hydronephrosis and hydroureter. From cystography and VCUG examination, low capacity bladder, grade 1 VUR on the right side, grade 4 VUR on the left side accompanied by bilateral hydronephrosis and hydroureter. The patient has a history of right nephrectomy in 2014 for pyonephrosis due to kidney stones. The patient was then subjected to bladder augmentation using a segment of the ileum (ileocystoplasty) in 2015. In the postoperative evaluation, clinical symptoms, radiological and uroflowmetric examinations were evaluated. CONCLUSION: The detubularization form offers greater volume and lower pressure in the reservoir to augment the bladder.

Percutaneous Cystolitholapaxy Using the LithoClast Trilogy for Multiple Bladder Stones.

Background: Multiple large bladder calculi are traditionally managed through open cystolithotomy or transurethrally in patients who have an open bladder neck. Open procedures are technically challenging in patients who may have had multiple previous open surgeries, and may be associated with significant morbidity in patients with a high comorbid burden. Therefore, a percutaneous approach to such stones has been used especially when there is a closed bladder neck, and has been shown to be effective. There are a number of available devices for breaking stones in these approaches, the newest of which is the LithoClast Trilogy™ (EMS, Nyon, Switzerland) device, a probe that provides ultrasonic and mechanical calculi fragmentation and suction in a single instrument. Case Presentation: We describe the first reported case of percutaneous cystolitholapaxy using the LithoClast Trilogy device in a 41-year-old woman with spina bifida, and multiple large bladder calculi with a history of ileocystoplasty and Mitrofanoff formation, and a bladder neck closure for neuropathic bladder. The calculi measured 31 and 25 mm, and had a volume of 19.6 and 7.9 cm3 and average HU of 408 and 462, respectively. The calculi were composed of 37% calcium phosphate and 63% magnesium ammonium phosphate. Conclusion: We demonstrate that this approach can be used as a viable alternative to open surgery, which is of particular importance for complex patients who have undergone multiple previous open operations, and who may have a high comorbid burden.

Robot-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy in children: Step-by-step and modifications to UChicago technique.

Objective: To describe the step-by-step techniques and modifications for robot-assisted augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy in a pediatric population with updated institutional results. Introduction: Robot-assisted laparoscopic augmentation ileocystoplasty with Mitrofanoff appendicovesicostomy (RALIMA) protects the upper urinary tract and reestablishes continence in patients with refractory neurogenic bladder. Robotic assistance could provide the benefits of minimally invasive surgery without the challenges of pure laparoscopy. Here, we focus on the outcomes of RALIMA with salient tips and modifications of the technique. Methods: We performed a retrospective review of our robotic database and identified 24 patients who underwent attempted robot-assisted laparoscopic augmentation ileocystoplasty (RALI) between 2008 and 2017 by a single surgeon at an academic center. Outcomes of interest included operative time, hospitalization time, postoperative complications, and change in bladder capacity. RALI and all concomitant procedures were performed using the da Vinci® surgical system (Intuitive Surgical, Sunnyvale, CA, USA). Results: Of 24 patients, 20 successfully underwent RALI. Eighty percent underwent concomitant appendicovesicostomy (APV), 40% underwent antegrade continence enema channel formation (ACE), and 30% underwent a bladder neck procedure. Mean operative time was 573 minutes and the most recent RALIMA was 360 minutes. The average return to regular diet was 3.9 days and length of stay was 6.9 days. Mean change in bladder capacity was 244% postoperatively. Thirty-day complications were noted in 35% of patients; one Clavian grade I (5%) complication, five grade II (25%) complications, and one grade IIIb (5%) complication. With a median follow-up of 83.1 months we note a 25% incidence of bladder stones, 15% upper tract stones, 5% incidence of bladder rupture, and 5% small bowel obstruction. No patients required re-augmentation in the follow-up period. Conclusions: RALI has similar functional outcomes and complications when compared with the open augmentation ileocystoplasty literature. RALI is desirable due to favorable pain control with decreased length of stay. Long-term outcomes after RALI are similar to the open approach. As the operative time is currently the largest point of criticism with the robotic approach, we discuss modifications to decrease the operative time.

Clam augmentation enterocystoplasty as management of urge urinary incontinence and reduced bladder capacity.

Objectives: Third line treatment of urge urinary incontinence (UUI) and/or reduced bladder capacity is bladder augmentation. The aim of this study was to investigate whether clam enterocystoplasty (CECP) was an efficient treatment for patients who were refractory to conservative treatments of UUI and small functional bladder capacity and secondly if there was a difference in outcome in patients with neurogenic and non-neurogenic bladders.Methods: We evaluated 118 patients retrospectively treated in the period 2006-2018 at a single university hospital. Data were collected retrospectively. Patient groups were compared with Wilcoxon signed-rank test and Fisher's exact test.Results: Overall, 76% became continent with 92% using clean intermittent self-catherization (CISC) of patients with neurogenic bladder, 82% became continent and 100% were using CISC, whereas of patients with non-neurogenic bladder 64% became continence and 77% were using CISC. The median overall improvement of capacity was 296.5 mL (IQR: 142-440), 310 mL (186-467) in the neurogenic group and 214 mL (IQR: 126.8-361.5) in non-neurogenic (p = 0.01).Conclusion: CECP is an efficient treatment in UUI and reduced bladder capacity. Difference in outcome was seen with neurogenic patients having a bigger functional capacity and a higher rate of continence compared to the non-neurogenic.

The local microbiome after pediatric bladder augmentation: intestinal segments and the native urinary bladder host similar mucosal microbiota.

INTRODUCTION: Next-generation sequencing (NGS) techniques have provided novel insights into the microbiome of the urinary bladder (UB). In children after bladder augmentation using either ileum (ileocystoplasty, ICP) or colon (colocystoplasty, CCP), the fate of the mucosal microbiome introduced into the urinary tract remains unknown. OBJECTIVE: The aim was to compare the mucosal microbiome of the native UB vs the augmented intestinal segment (IS) using NGS. STUDY DESIGN: Twelve children after bladder augmentation (ICP n = 6, CCP n = 6) were included. Biopsies were taken during routine postoperative cystoscopy from the native UB and the IS. Specimens underwent whole-genome DNA extraction, 16S rRNA gene amplification, NGS, and Quantitative Insights Into Microbial Ecology (QIIME) data analysis. Downstream statistical data analyses were performed in Calypso. RESULTS: Patients' median age at the time of surgery was 11 years (6-17 years), and the median interval between augmentation and sampling was 7 years (4-13 years). α-Diversity (Shannon diversity index) was not significantly different between IS vs UB, ICP vs CCP, and male vs female. No general differences in the overall bacterial pattern (ß-diversity) were found between IS, UB, ICP, and CCP groups. The groups overlapped in principal coordinate analysis (PCoA) and non-metric multidimensional scaling (NMDS) analysis (Figure). Age at sampling had a statistically significant influence on ß-diversity at the genus level. Corynebacterium, Pseudoxanthomonas, Lactobacillus, Flavobacterium, and Micrococcus were the most dominating taxa detected over all samples. There was an obvious dominance of the genus Corynebacterium in the samples taken from the UB and IS in both ICP and CCP patients. Limitations of this study include the relatively small number of patients. CONCLUSION: After bladder augmentation, the native UB and augmented ISs (ICP and CCP) host similar microbiota despite their distinct differences of originating mucosal anatomy.

Bladder augmentation in children: current problems and experimental strategies for reconstruction.

Bladder augmentation is a demanding surgical procedure and exclusively offered for selected children and has only a small spectrum of indications. Paediatric bladder voiding dysfunction occurs either on a basis of neurological dysfunction caused by congenital neural tube defects or on a basis of rare congenital anatomic malformations. Neurogenic bladder dysfunction often responds well to a combination of specific drugs and/or intermittent self-catheterization. However, selected patients with spinal dysraphism and children with congenital malformations like bladder exstrophy and resulting small bladder capacity might require bladder augmentation. Ileocystoplasty is the preferred method of bladder augmentation to date. Because of the substantial long-and short-term morbidity of augmentation cystoplasty, recent studies have tried to incorporate new techniques and technologies, such as the use of biomaterials to overcome or reduce the adverse effects. In this regard, homografts and allografts have been implemented in bladder augmentation with varying results, but recent studies have shown promising data in terms of proliferation of urothelium and muscle cells by using biological silk grafts.

Expanding the indications of robotic surgery in urology: A systematic review of the literature.

OBJECTIVES: To evaluate the recent developments in robotic urological surgery, as the introduction of robotic technology has overcome many of the difficulties of pure laparoscopic surgery enabling surgeons to perform complex minimally invasive procedures with a shorter learning curve. Robot-assisted surgery (RAS) is now offered as the standard for various surgical procedures across multiple specialities. METHODS: A systematic search of MEDLINE, PubMed and EMBASE databases was performed to identify studies evaluating robot-assisted simple prostatectomy, salvage radical prostatectomy, surgery for urolithiasis, distal ureteric reconstruction, retroperitoneal lymph node dissection, augmentation ileocystoplasty, and artificial urinary sphincter insertion. Article titles, abstracts, and full text manuscripts were screened to identify relevant studies, which then underwent data extraction and analysis. RESULTS: In all, 72 studies evaluating the above techniques were identified. Almost all studies were retrospective single-arm case series. RAS appears to be associated with reduced morbidity, less blood loss, reduced length of stay, and comparable clinical outcomes in comparison to the corresponding open procedures, whilst having a shorter operative duration and learning curve compared to the equivalent laparoscopic techniques. CONCLUSION: Emerging data demonstrate that the breadth and complexity of urological procedures performed using the da Vinci® platform (Intuitive Surgical Inc., Sunnyvale, CA, USA) is continually expanding. There is a gaining consensus that RAS is producing promising surgical results in a wide range of procedures. A major limitation of the current literature is the sparsity of comparative trials evaluating these procedures.

Bladder Reconstruction with Bowel: Robot-Assisted Laparoscopic Ileocystoplasty with Mitrofanoff Appendicovesicostomy in Pediatric Patients.

Neurogenic bladder occur as a consequence of several conditions, most commonly posterior urethral valves syndrome, spina bifida, tethered cord, sacral agenesis, and Arnold-Chiari malformation. It is characterized by diminished bladder capacity and/or reduced compliance, associated with high-pressure voiding that can lead to deterioration of renal function if left untreated. When medical management fails, bladder reconstruction with bowel (aumentation ileocystoplasty) becomes the treatment of choice for these patients. In most cases, it is accompanied by the creation of a continent catheterizable channel, with the appendix being the most commonly used conduit (Mitrofanoff appendicovesicostomy). Conventional open surgery has proven to be an efficient and safe approach in these patients. However, robot-assisted surgery not only offers a cosmetic advantage, but also results in a shorter hospital stay, less postoperative pain, and even decreased number of adhesions (as shown in porcine models). Nevertheless, the complexity of this technique has limited the wide adoption of this approach. We seek to provide a technical guide to robot-assisted laparoscopic ileocystoplasty and Mitrofanoff appendicovesicostomy in pediatric patients, as well as a critical review of literature about the perioperative care of these patients.

The Double Dutch technique: A new way of creating an ileocystoplasty with a lengthy catheterizable ileal tube.

INTRODUCTION: A tubularized conduit from an open 2-cm vascularized ileal segment is a frequently used technique to create a continent catheterizable channel in cases of an inappropriate or absent appendix. In the long term, many patients experience catheterization problems with the classic ileal segment tube, and even more with spiral or double-segment tubes. OBJECTIVE: The objective of this paper was to introduce an ileocystoplasty modification combined with a long ileal segment tube that has better support by surrounding tissue than other lengthy ileal segment tubes. Briefly summarized, this newly introduced method begins with isolating approximately 30 cm of ileum and dividing it into two parts. Two strips are then created and closed as a double-length tube. The ileal segments are opened antimesenterically and closed over the tube in the middle. The lower part of the tube is implanted with a submucosal tunnel in the bladder wall, and the ileal patch is then anastomosed with the bladder. The tube is anastomosed to the umbilicus in an ordinary way without any traction (see Summary Fig.). STUDY DESIGN: Between May 2005 and November 2012 the new technique was used at the current institution in nine children who needed an ileocystoplasty (mean age: 9 years and 3 months). Underlying etiology was neurogenic bladder in seven cases and epispadias in two. RESULTS: All patients ultimately had stomas without leakage or strictures. During follow-up, three of nine tubes developed stenoses that were corrected; four stomas in total had some sort of surgical revision. Median follow-up was 93 months. Intermittent catheterization was uncomplicated in all at this time. DISCUSSION: With this modification of the standard technique it seemed to be possible to create a more stable channel. The blood supply of the tube was secured by completely embedding the mesentery of the tube. Limitations included the small number of patients treated so far. CONCLUSION: The lengthy tubes appeared to be straight and well supported by the surrounding tissues, which prevented kinking and sacculation. It is hoped that this technique will have better results and fewer complications at long-term follow-up.

Our experiences with robot- assisted laparoscopic surgery in pediatric patients: the first case series from Turkey.

OBJECTIVE: Robotic surgery is a leading treatment option for minimally invasive surgery and has an increasing popularity in pediatric population, as well. In this article, we reported our case series of robot-assisted laparoscopic surgery in pediatric population. MATERIAL AND METHODS: We retrospectively reviewed 29 consecutive pediatric patients who underwent robot- assisted procedures between May 2014 and October 2016. Patient demographics, hospitalization time, estimated blood loss, robotic time and total operative and peri-, and post-operative complications were evaluated. RESULTS: A total of 24 ureter units (18 patients) with grade 1-5 vesicoureteral reflux in 13 female and 5 male, 1 male patient with vesicoureteral stenosis were underwent robot- assisted laparoscopic ureteral reimplantation (RALUR). All patients had complete resolution after surgery. Robot-assisted laparoscopic pyeloplasty (RALP) was performed in 6 patients with ureteropelvic junction obstruction. All patients had complete resolution after surgery. Completely intracorporeal robotic assisted laparoscopic augmentation ileocystoplasty (RLAIC) was applied to two patients with neurogenic bladder. The symptoms and preoperative hydronephrosis were regressed on the first month of follow-up. Robot-assisted laparoscopic reduction cystoplasty (RALRC) was performed in 14-year-old boy with a bladder diverticula and recurrent urinary tract infection. The last case was eleven- year-old female patient with non-functioning kidney. She had recurrent urinary tract infections and was treated with robotic assisted laparoscopic nephrectomy (RALN). CONCLUSION: Robot-assisted laparoscopic surgery is safe and efficient in pediatric population. Although open surgery is still the gold standard for many pediatric diseases, inherent reconstructive advantages of robotic assisted laparoscopy have a chance to change this view.

Feasibility, Morbidity, and Functional Results of Supratrigonal Cystectomy with Augmentation Ileocystoplasty by Combined Robot-Assisted Laparoscopy and Mini-Laparotomy Approach.

OBJECTIVES: Evaluation of the feasibility, morbidity, learning curve, and functional results of robotic supratrigonal cystectomy with augmentation ileocystoplasty (RSCAI). MATERIALS AND METHODS: RSCAI was performed in 19 patients between 2012 and 2016. Thirteen patients (66.4%) presented refractory detrusor overactivity or impaired compliance and 6 patients (31.6%) had painful bladder syndrome. A combined robot-assisted laparoscopy and mini-laparotomy approach was performed. Early (<30 days) and late (>30 days) complications were reported according to the Clavien-Dindo classification. Functional results were analyzed according to the surgical indication. RESULTS: Mean total operating time was 288.7 ± 92.1 minutes. Mean intraoperative blood loss was 147.4 ± 144.8 mL. Mean length of hospital stay in the surgical ward was 9.4 ± 3.7 days. Mean duration of bladder drainage was 23.3 ± 4.1 days. For surgeons who regularly performed robot-assisted laparoscopy, the learning curve of this technique, as assessed by the operating time, required almost five operations. No major (Clavien-Dindo >2) early (0%) or late (0%) postoperative complication was observed. Early minor complications were observed in 47.4% of cases, usually consisting of pyelonephritis (21.1%). Late minor complications (10.5%) were Clavien-Dindo grade I. Mean follow-up was 13.6 ± 10.1 months. The majority of patients (94.7%) obtained functional improvement of their disease in terms of pain, functional bladder capacity, or bladder compliance. CONCLUSION: Our RSCAI technique is a reliable technique with no early or late major postoperative complications reported in this series. This technique allows patients to be operated by minimally invasive surgery with very satisfactory long-term functional results.