Paediatric urology in Sub-Saharan Africa: challenges and opportunities.

The need for paediatric urological care in low- and middle-income countries in sub-Saharan Africa (SSA) is enormous due to a burgeoning paediatric-aged population and a disproportionate burden of congenital malformations. There are formidable challenges in the provision of a skilled workforce and appropriate infrastructure, resulting in a huge unmet need with consequent effects on the long-term health and prosperity of the population. Constraints of funding, geography, culture, surgical and anaesthetic skills, and instrumentation means that many conditions present late and with complications that could have been avoided by an earlier attendance. It also means that the management of congenital malformations, e.g., bladder exstrophy and congenital obstructive posterior urethral membrane, differ substantially from that seen in the developed world, with the outlook for children with renal failure being particularly bleak. Collaborations between paediatric urologists from high- and low-income countries are beginning to help with the development of a surgical infrastructure customised to paediatric care, and with the training of specific paediatric urological knowledge and skills. These collaborations, whilst welcome, still require substantial expansion to achieve more equitable access to appropriate paediatric urological care for children in SSA. Future efforts have to focus on the creation of sustainable and equal partnerships between urologists from low- and high-income healthcare environments, with an emphasis on providing sustainable management, appropriate to local need and available resources. The provision of shared learning, utilising the benefits of global digital communication, will improve mutual understanding of needs in a resource-poor environment and the involvement of trainees from both income settings can help perpetuate long-term collaborations.

A multinational survey on the management of the urinary tract in newborns with spina bifida: Are we following current EAU/ESPU guidelines?

AIMS: In August 2019, the European Association of Urology (EAU) and European Society for Paediatric Urology (ESPU) published updated guidelines on the management of neurogenic bladder in children and adolescents. Our study aimed to establish whether members of the ESPU are adhering to these guidelines. METHODS: We designed a survey comprising 26 questions using SurveyMonkey®. Respondents were asked about management of neurogenic bladder at birth in newborns with spina bifida (SB), urological investigations, as well as short and long-term follow-up in their institutions. RESULTS: There were 103 respondents to the survey (754 recipients, giving a response rate of 14%) spanning 36 countries. 100% of respondents carry out a renal/bladder ultrasound at birth. Only 53% routinely commence clean intermittent catheterization soon after birth as recommended by the guidelines. Only 56% recommend anticholinergic medications after abnormal videourodynamics (VUDs). The guidelines recommend the use of continued antibiotic prophylaxis if there is evidence of vesicoureteral reflux and hostile bladder/non-conclusive results on VUDs which is followed by only 30% of providers. 63% of respondents carry out baseline VUDs at the recommended time. Seeing larger volumes of SB patients, having a formal SB protocol, having formal SB multidisciplinary clinics and working in a tertiary referral center did not make respondents more likely to adhere to guidelines. CONCLUSIONS: Our survey demonstrated that large variations from the EAU/ESPU guidelines exist in practice. The study confirms that further work is required across institutions and countries to implement these evidence-based recommendations for standardized practice.

Experience with detrusorotomy in children by open and robotic approach.

PURPOSE: To present the author's experience with detrusorotomy (DM) for refractory detrusor overactivity (RDO) with open and robotic approach. METHODS: Children who underwent DM for RDO in a single surgeon series since 2012 were identified from a prospectively maintained database. Those who completed the defined strict bladder cycling regime postoperatively were included in this report excluding those who failed the bladder cycling regime. RESULTS: Ten children (M7: F3) were included in this report, six open and four robotic. All procedures were completed with no conversion to open in the robotic group. There were no intra or postoperative complications from the procedures. Duration of procedure was lower in robotic group (125 min) vs the open group at (208 min). Hospital stay was also lower in the robotic group (2.7 days) compared to the open group (5.6 days). All children in open group had concomitant Mitrofanoff channel created for bladder drainage. One child in robotic group had concomitant Mitrofanoff channel during DM. Median follow-up is longer at 54 months (31-82) in open group compared to 14 months (5-21). All children are clinically well with safe upper tracts on US scan in both series. Estimated % change in bladder capacity is similar in both groups at 140 (90-200) and 126 (80-200) for open and robotic groups, respectively. CONCLUSIONS: DM as an extension of medical treatment for RDO can be performed safely and is effective in children. Preliminary experience with robotic approach to DM is promising with reduced duration of procedure and hospital stay.

Relevance of current guidelines in the management of VUR.

UNLABELLED: In recent years, there have been fundamental changes in the understanding of vesicoureteral reflux (VUR). This is reflected by current international guidelines that cover diagnosis, screening, and treatment of VUR. However, literature is still lacking and many questions are unsolved. In this article, we shortly review the important aspects of the current guidelines. Due to the lack of high-powered randomized controlled trials, guidelines often are based on an expert's opinion rather than evidence. In this review article, we address the controversies in the management of VUR; siblings and children with antenatally diagnosed hydronephrosis and the management of a patient with VUR. CONCLUSION: With an individualized approach and patient risk stratification, the goal today must be to address the clinical problem, avoid unnecessary tests, and provide good quality of life for the patient and parents.

Multi-stakeholder opinion statement on the care of individuals born with differences of sex development: common ground and opportunities for improvement.

BACKGROUND: In the last 15 years, the care provided for individuals born with differences of sex development (DSD) has evolved, with a strong emphasis on interdisciplinary approaches. However, these developments have not convinced some stakeholders to embrace the current model of care. This care model has also paid insufficient attention to socio-cultural differences and global inequalities. SUMMARY: This article is an opinion statement, resulting from in-depth discussions and reflection among clinicians, patients, and family support organizations based in the US and Europe, where we seek areas of common ground and try to identify opportunities to further develop resources. The product of these conversations is summarized in 10 panels. The corresponding sections provide additional discussion on some of the panel items. KEY MESSAGES: Participants identified areas of agreement and gained a deeper understanding of the reasons behind disagreements on certain matters and identified the necessary steps to foster future consensus. We offer preliminary recommendations for guiding clinical management and resource allocation. By promoting a broader consensus, we aim to enhance the quality of care and well-being for individuals of all ages who have a DSD.

Robot-assisted reconstructive surgery of lower urinary tract in children: a narrative review on technical aspects and current literature.

Background and Objective: Robotic approach is used widely for paediatric upper tract urinary reconstruction. This is a narrative review looking at the current status of robotic approach in lower urinary tract reconstruction. The aim of this article is to highlight the important technical aspects of commonly performed robotic lower urinary tract reconstructive surgeries and review the current literature. Methods: MEDLINE database search was conducted using MeSH terms and Boolean operators from Jan 2000 to Jun 2022. Abstracts were screened to exclude those in languages other than English as also articles pertaining to (I) upper urinary tract surgery, (II) only laparoscopic surgery (not robot-assisted) and (III) non-urological topics. Selected articles were then reviewed and search expanded to include their references with a focus on advanced lower urinary tract reconstruction. Key Content and Findings: The technical aspects of robotic ureteric reimplantation, continent catheterisable channel and autoaugmentation are discussed in detail. The early outcomes are comparable to open surgery. The true advantage of robotic approach becomes apparent when performing lower urinary tract reconstruction, where space in the pelvis is limited and access is challenging. Only a few centres are currently performing bladder neck surgery and bladder augmentation. Conclusions: Robotic lower urinary tract reconstruction in children is feasible and safe. Robotic approach offers better access, especially in the limited space within the pelvis. It reduces blood loss and post-operative pain allowing early recovery and discharge. Long-term follow-up with increasing experience could further validate these early observations.

Tissue engineering potential of urothelial cells from diseased bladders.

PURPOSE: We examined the suitability of urothelium from patients with abnormal bladders for use in surgical reconstruction using a tissue engineering approach that would require autologous urothelium to be expanded by propagation in cell culture. MATERIALS AND METHODS: Resection specimens from 8 children (median age 9.8 years) with abnormal bladders (neuropathic in 4, posterior urethral valves in 2, epispadias in 1, nonneurogenic in 1) were collected with informed parental consent during planned urological procedures. Six patients had recurrent urinary tract infections and 7 underwent frequent intermittent catheterization. A representative sample was immunohistologically processed to assess urothelial proliferation and differentiation status, and the remaining 7 cases were processed for urothelial cell culture. Five normal adult urothelial samples were included as controls. RESULTS: Immunohistological assessment indicated that 3 of 8 samples lacked urothelial differentiation associated expression of UPK3a or CK20. Four of 7 samples resulted in successful primary culture, with 1 sample lost to underlying infection and 2 not surviving in culture. All 4 cultures grew beyond passage 3 before senescence but all showed reduced proliferation capacity and a compromised ability to form a barrier urothelium compared to controls. CONCLUSIONS: While normal human urothelium is highly regenerative and derived cells are highly proliferative in culture, our results with urothelium from abnormal pediatric bladders indicate a reduced capacity for proliferation and differentiation in vitro. This finding may indicate a need to identify alternative cell sources for engineered bladder reconstruction.

Ureterocalicostomy in children: 12 years experience in a single centre.

OBJECTIVE: • To document the outcome of ureterocalicostomy in children. PATIENTS AND METHODS: • The outcomes of 13 children who had undergone ureterocalicostomy consecutively under the care of two paediatric urologists between 1997 and 2009 were evaluated retrospectively. • Ureterocalicostomy was performed as the primary procedure in four children with horseshoe kidney and four children presenting with gross pelvi-ureteric junction (PUJ) obstruction. • In the remaining five children, it was performed as a secondary procedure for recurrent PUJ obstruction after previous pyeloplasty. • An open approach was employed in 12 patients, whereas, in one patient, it was performed by a laparoscopically-assisted technique. RESULTS: • Mean age at operation was 9.3 years and the mean (range) duration of follow-up was 2.6 (0.3-7.0) years. Twelve children (92%) experienced a good functional outcome following ureterocalicostomy, as defined by reduced dilatation and improved drainage on postoperative ultrasonography and/or isotope imaging. • However one child (8%) developed symptomatic anastomotic obstruction 5 months after primary ureterocalicostomy for obstruction in a horseshoe kidney. Surgical revision was successful, with good drainage, preservation of differential function and relief of symptoms on further follow-up to 3 years. CONCLUSIONS: • Ureterocalicostomy provides a versatile and reliable means of relieving obstruction for a variety of indications, including horseshoe kidney, recurrent PUJ obstruction and gross PUJ obstruction with unfavourable anatomy. • Approximation of ureteric and caliceal urothelium and excision of renal parenchyma in the proximity to the anastomosis are the key steps for securing a satisfactory outcome.

Efficacy of bladder irrigation and surveillance program in prevention of urinary tract infections and bladder calculi in children with an ileocystoplasty and bladder neck repair.

PURPOSE: In children with bladder augmentation and particularly in those with bladder neck repair (BNR), urinary tract infections (UTI) and bladder calculi are a recognised problem. Bladder irrigation potentially prevents these complications. Our aim was to investigate the efficacy of bladder irrigation supported by a surveillance program in prevention of UTI and bladder calculi in these children. METHODS: A cohort of children subjected to ileocystoplasty with a stoma for clean intermittent self catheterisation with or without BNR was retrospectively analysed. The children were subjected to bladder irrigation and monitored by Clinical Nurse Specialists (CNS) according to a protocol. Patients' demographics, treatment methods and postoperative management were reviewed. Compliance to bladder irrigation was assessed with questionnaires. UTI recurrence and bladder calculi during follow-up were assessed. RESULTS: 28 children were included in this study. The median follow-up was 48 months (range 6-87). Compliance could be assessed in all children, except in one child (3.5%). There was no recurrent UTI reported, bladder calculi occurred in two children (7%). CONCLUSION: Our bladder irrigation regime resulted in a low incidence of calculi by preventing recurrent UTI. The surveillance program resulted in high compliance rates in children with an augmented bladder with or without BNR.

Augmentation of the insufficient tissue bed for surgical repair of hypospadias using acellular matrix grafts: A proof of concept study.

Acellular matrices produced by tissue decellularisation are reported to have tissue integrative properties. We examined the potential for incorporating acellular matrix grafts during procedures where there is an inadequate natural tissue bed to support an enduring surgical repair. Hypospadias is a common congenital defect requiring surgery, but associated with long-term complications due to deficiencies in the quality and quantity of the host tissue bed at the repair site. Biomaterials were implanted as single on-lay grafts in a peri-urethral position in male pigs. Two acellular tissue matrices were compared: full-thickness porcine acellular bladder matrix (PABM) and commercially-sourced cross-linked acellular matrix from porcine dermis (Permacol™). Anatomical and immunohistological outcomes were assessed 3 months post-surgery. There were no complications and surgical sites underwent full cosmetic repair. PABM grafts were fully incorporated, whilst Permacol™ grafts remained palpable. Immunohistochemical analysis indicated a non-inflammatory, remodelling-type response to both biomaterials. PABM implants showed extensive stromal cell infiltration and neovascularisation, with a significantly higher density of cells (p < 0.001) than Permacol™, which showed poor cellularisation and partial encapsulation. This study supports the anti-inflammatory and tissue-integrative nature of non-crosslinked acellular matrices and provides proof-of-principle for incorporating acellular matrices during surgical procedures, such as in primary complex hypospadias repair.

Paediatric sutureless circumcision: a systematic literature review.

Circumcision can be undertaken using a variety of techniques. For the technique to be successful, it should be easy to perform, avoid excessive haemorrhage and achieve a good cosmetic and functional result with minimal postoperative care. Naturally, there are differences between circumcision in the paediatric and adult populations and here we review the literature on recent advances that have been made in paediatric circumcision and the use of a sutureless technique with tissue glue for wound approximation.

Searching for the Least Invasive Management of Pelvi-Ureteric Junction Obstruction in Children: A Critical Literature Review of Comparative Outcomes.

Introduction: To review the published evidence on the minimally invasive pyeloplasty techniques available currently with particular emphasis on the comparative data about the various minimally invasive alternatives to treat pelvi-ureteric junction obstruction and gauge if one should be favored under certain circumstances. Materials and Methods: Non-systematic review of literature on open and minimally invasive pyeloplasty including various kinds of laparoscopic procedures, the robotic-assisted laparoscopic pyeloplasty, and endourological procedures. Results: Any particular minimally invasive pyeloplasty procedure seems feasible in experienced hands, irrespective of age including infants. Comparative data suggest that the robotic-assisted procedure has gained wider acceptance mainly because it is ergonomically more suited to surgeon well-being and facilitates advanced skills with dexterity thanks to 7 degrees of freedom. However, costs remain the major drawback of robotic surgery. In young children and infants, instead, open surgery can be performed via a relatively small incision and quicker time frame. Conclusions: The best approach for pyeloplasty is still a matter of debate. The robotic approach has gained increasing acceptance over the last years with major advantages of the surgeon well-being and ergonomics and the ease of suturing. Evidence, however, may favor the use of open surgery in infancy.

European Association of Urology Guidelines Office Rapid Reaction Group: An Organisation-wide Collaborative Effort to Adapt the European Association of Urology Guidelines Recommendations to the Coronavirus Disease 2019 Era.

The coronavirus disease 2019 (COVID-19) pandemic is unlike anything seen before by modern science-based medicine. Health systems across the world are struggling to manage it. Added to this struggle are the effects of social confinement and isolation. This brings into question whether the latest guidelines are relevant in this crisis. We aim to support urologists in this difficult situation by providing tools that can facilitate decision making, and to minimise the impact and risks for both patients and health professionals delivering urological care, whenever possible. We hope that the revised recommendations will assist urologist surgeons across the globe to guide the management of urological conditions during the current COVID-19 pandemic.

The use of an antegrade continence enema stopper in catheterizable channels virtually eliminates the incidence of stomal stenosis: preliminary experience.

PURPOSE: We report the effectiveness of an antegrade continence enema stopper device in preventing stomal stenosis in catheterizable channels. MATERIALS AND METHODS: All cases in which a channel was created for clean intermittent catheterization during a 5-year period beginning in May 2002 were included in the analysis. For the first 31 months the catheterizable channels were used for clean intermittent catheterization but were not kept patent between catheterizations (group 1, 19 patients). For the next 29 months we began to use an antegrade continence enema stopper in the stoma between catheterizations for a period of 3 to 6 months postoperatively (group 2, 14 patients). RESULTS: A total of 33 catheterizable channels were studied. Six catheterizable channels in group 1 (32%) had to be revised within 6 months of reconstruction. No catheterizable channel in group 2 had to be revised. This difference is statistically significant (p = 0.02). CONCLUSIONS: An antegrade continence enema stopper inserted into the catheterizable channel for 3 to 6 months postoperatively effectively eliminates the incidence of stomal stenosis.

Robotic Approach to Creation of Continent Catheterisable Channels-Technical Steps, Current Status, and Review of Outcomes.

Purpose: To report the current status of Robotic approach to creation of Catheterisable channel (CC) with the author's personal experience compared to published literature on technical steps, follow up, and outcomes. Methods: CC data was extracted from the prospective database set up for all Robotic pediatric urology procedures performed by the author at his institution. A literature search was then performed to look at the evidence base. Results: Eighteen consecutive cases (8M:7F) of Robotic approach to creation of CC was identified and included. All attempted cases were successfully completed without any conversion to open approach. Median age at surgery was 10.75 years (IQR 6.9-16.5); Median OT 197 min (IQR 131-295) with concomitant procedures in 4 cases. Appendix was used in 14 cases as CC conduit and distal ureter in 4 cases. Median Length of stay (LOS) was 2.75 days (IQR 2-6) and Median FU 27.3 m. Whilst FU duration is comparable to published series, average OT and LOS was much lower in this series. The LOS in this robotic series is much lower than the author's experience with open approach (2.75 vs. 5.8 days). No major complications postoperatively except for one exit site wound infection managed conservatively. None of the CC have been revised in this series and all channels are patent with 12 F or 14 F admissible catheter size. There were no cases of incontinence related to technique of creation of CC and no incidence of exit site stomal stenosis with use of ACE stopper until channel matures and Clean intermittent catheterisation (CIC) is established. Conclusion: Robotic approach to CC is feasible, safe with excellent outcomes and minimum morbidity. Robotic complex bladder reconstructive surgery offers some advantages to children compared to open approach but is only currently performed in few tertiary centers with expertise.

The long-term outcome of prenatally detected posterior urethral valves: a 10 to 23-year follow-up study.

OBJECTIVE: To document the functional outcome of patients with prenatally detected posterior urethral valves (PUV) in the second decade of life, and to evaluate the possible impact of prenatal diagnosis on the long-term outcome of this condition. PATIENTS AND METHODS: We analysed the functional outcome of 25 patients with prenatally detected PUV born between 1984 and 1996, whose mean (range) age at follow-up was 17.7 (10-23) years. The findings were compared with those in 17 patients (mean age 16.1 years) who had presented clinically to our unit during the same period. The duration of follow-up in both groups was >or=10 years. Late outcomes were also compared with published data for PUV. Outcome measures included; death, incidence of end-stage renal failure (ESRF), age at transplantation and the most the recently available plasma creatinine level in untransplanted patients. We also examined any possible association between functional outcome and early predictors, including nadir plasma creatinine level at <1 year and vesico-ureteric reflux (VUR). RESULTS: Three patients died (12%), two as neonates and one aged 3 years. Of five patients who had been shunted in utero, four died or developed early-onset renal failure. In the 23 prenatally detected patients who survived the neonatal period, four (17%) had a renal transplant at a mean (range) age of 6.5 (3.0-12.0) years. Of 19 patients with prenatally detected PUV who had not been transplanted in the first 12 years of life, only one (5%) developed new-onset ESRF at 10.0-23.4 years whilst 11 (58%) of these patients had normal creatinine values. In the untransplanted patients there was a statistically significant correlation between age and plasma creatinine level, but no correlation between late functional outcome and nadir creatinine in the first year of life, or bilateral VUR. CONCLUSIONS: Prenatal diagnosis had little impact on mortality or ESRF in the first decade of life. This appears to be largely predetermined by renal dysplasia and the severity of intrauterine obstruction. However, the functional outcome of patients with prenatally detected PUV aged 10-23 years was considerably better than published long-term data and the outcome of clinically presenting patients in our study. These findings suggest that the long-term prognosis of PUV of intermediate severity might be improved by prenatal diagnosis.

Current Use of and Indications for Robot-assisted Surgery in Paediatric Urology.

The use of robot-assisted surgery (RAS) by paediatric urologists is increasing. This mini review looks at the current status of RAS in paediatric urology. The challenges involved in RAS use in children are reviewed, as well as the indications for and feasibility of procedures performed and, where possible, outcomes with RAS. PATIENT SUMMARY: The current status of robot-assisted surgery (RAS) in paediatric urology, together with the challenges in using RAS for children is outlined in this mini review. Innovative adaptation has pushed the boundaries as regards the feasibility of RAS procedures in children with good outcomes.

Single-stage urethroplasty with buccal mucosal inlay graft for stricture caused by balanitis xerotica obliterans in boys: Outcomes in the medium term.

INTRODUCTION: Balanitis xerotica obliterans (BXO) is a common condition that can affect the foreskin, glans, meatus, and urethra, and rarely can also involve urethra leading to stricture. Numerous procedures have been suggested to treat urethral stricture secondary to BXO but these have had variable results. OBJECTIVE: We describe the first prospective study of a single stage buccal mucosal inlay grafting in children with urethral strictures resistant to existing remedies. MATERIALS AND METHODS: We treated five boys with resistant urethral strictures secondary to BXO with a single stage buccal mucosal inlay graft (BMIG, Figure). Uroflowmetry was performed both pre- and post-operatively. Functional outcome was the prime measure determining success. RESULT: All the boys had a successful functional outcome and all expressed satisfaction with cosmetic outcome as well. Uroflow parameters improved remarkably, with maximum and mean urinary flow rates significantly improved from 4.2 mL/s to 26 mL/s (p = 0.0002) and from 1.6 mL/s to 12.2 mL/s (p = 0.003), respectively. Median follow-up was 34 months (range 30-42 months). DISCUSSION: This paper is the first to describe the successful use of buccal mucosal inlay grafts to treat refractory BXO stricture in children. Various surgical techniques have been proposed particularly in adults including single vs. staged procedures, preputial and post auricular grafts, circular mucosal buccal grafts, as well as double mucosal grafts placed both ventrally and dorsally. All of these procedures are not without problems, and had variable results and outcome. Most of the procedures have been described in adult urethra and are not suitable for paediatric small calibre urethra. Our technique of dorsal inlay graft gives a robust structure to the distal urethra avoiding diverticula, pooling or urine spraying and can be placed onto proximal urethra as well. We have not seen recurrence of BXO in our buccal grafts, which is reported in other grafts from prepuce and post auricular grafts. The number of patients presented in our study is limited, nonetheless an excellent result in all our cases makes this a compelling approach to manage BXO urethral strictures. An early intervention in such cases is paramount to convert a salvage operation to a pre-emptive procedure. CONCLUSION: A single stage buccal mucosal inlay grafting in children with BXO stricture can offer an excellent outcome.

Robotic Pyeloplasty in Children: A "Barbed" Shortcut.

INTRODUCTION: Dismembered pyeloplasty remains the gold standard for the treatment of pelviureteric junction obstruction (PUJO). Robotic approach to this procedure has proven its efficacy and is gaining popularity. The introduction of barbed sutures such as "V-Loc™" (Covidien) has provided an addition to the sutures available for pyeloplasty. This work provides our experience with the V-Loc suture for closure of pelvis in children for robotic pyeloplasty (RP). MATERIALS AND METHODS: A review of 10 pediatric RP (da Vinci Robotic System) during which the V-Loc suture was used was performed. Comparison was made with 15 cases in which 5-0 Vicryl® suture was used as an alternative. Overall median age was 4 (range 9 months to 16 years), M:F = 14:9. All had confirmed PUJO on renal ultrasound and mercaptoacetyltriglycine (mertiatide) (MAG-3). RP was done in the standard Anderson-Hynes manner with the placement of a multilength JJ ureteral stent intraoperatively. Patients had removal of the JJ stent 6 weeks postoperatively followed by renal ultrasound 3-4 months later. RESULTS: Twenty-five RPs have been performed between May 2013 and November 2015, of which 10 have had closure of the pelvis performed using the V-Loc suture and 15 with Vicryl. One patient (6.67%) in the Vicryl group underwent redo-pyeloplasty secondary to a stent-related complication. The entire V-Loc group made an eventful initial recovery; however, four (40%) developed worsening hydronephrosis and drainage on ultrasound and MAG-3 after stent removal, despite remaining completely asymptomatic. These four required either restenting and observation (n = 1) or redo-pyeloplasty (n = 3). Histology demonstrated a "plaque-like" inflammatory reaction at the pelvic suture line. CONCLUSION: Closure of the pelvis using V-Loc suture material during RP can lead to a significant hydronephrosis requiring further procedures, including redo-pyeloplasty. These children can be asymptomatic and so extra vigilance on postoperative follow-up is essential.

Robot Docking Time: Cumulative Summation Analysis of a Procedure-Independent Learning Curve in Pediatric Urology.

PURPOSE: The learning curve is an important method of assessment of progression in the use of a new technique or device and, in the field of robotic surgery, is most commonly described for individual procedures, often concentrating on console time and outcomes. We contemplated whether a learning curve of the similar nature and duration was exhibited in the procedure-independent variable of docking time. MATERIALS AND METHODS: The time from first incision to end of robot docking was found for a single surgeon's first 55 robotic cases, which encompassed a range of pediatric urological procedures. Raw and cumulative summation (CUSUM) data were found and plotted, with learning- and maintenance-phase times compared statistically. RESULTS: A classical learning curve of ∼30 cases was found with a statistically significant reduction in time between learning and maintenance phases. CONCLUSIONS: A learning curve of similar nature and duration to procedure-specific analyses was found for docking time. The variability of port placement and robot positioning for multiple procedures further increases the significance of this result.