Paul H. Noh

Pediatric standard and robot-assisted laparoscopic pyeloplasty: a comparative single institution study.

PURPOSE We report our experience and compare the outcomes between standard and robot-assisted laparoscopic pyeloplasty to treat ureteropelvic junction obstruction in children. MATERIALS AND METHODS A retrospective cohort study was performed of all children who underwent standard or robot-assisted laparoscopic pyeloplasty for ureteropelvic junction obstruction at a single institution from October 2007 to January 2012. Indications for surgery included symptomatic obstruction and abnormal diuretic renal scan. A successful outcome was defined as resolution of clinical symptoms, improvement of hydronephrosis on ultrasound, stable ultrasound with resolution of symptoms or improvement of the drainage curve on diuretic renal scan. RESULTS We reviewed 18 patients (median age 8.1 years) who underwent standard and 46 (8.8 years) who underwent robot-assisted laparoscopic pyeloplasty (p = 0.194). Median operative time was 298 minutes (range 145 to 387) for standard and 209 minutes (106 to 540) for robot-assisted laparoscopic pyeloplasty (p = 0.008). Mean hospitalization was similar between the groups (1 day for standard vs 2 days for robot-assisted laparoscopic pyeloplasty, p = 0.246). Narcotic use was similar between the groups. Median followup was 43 months for standard and 22 months for robot-assisted laparoscopic pyeloplasty (p <0.01). Renal ultrasound showed postoperative improvement of hydronephrosis in 85% and stable disease in 15% of patients following robot-assisted laparoscopic pyeloplasty, and improvement in 89.5% and stable disease in 10.5% after standard laparoscopic pyeloplasty. Symptoms resolved in 100% of patients (38 of 38) after robot-assisted laparoscopic pyeloplasty and 87.5% of patients (7 of 8) after standard laparoscopic pyeloplasty. CONCLUSIONS Robot-assisted laparoscopic pyeloplasty and standard laparoscopic pyeloplasty are effective techniques to correct ureteropelvic junction obstruction, with similar outcomes. Robot-assisted laparoscopic pyeloplasty had a shorter operative time, and its success and complication rates are comparable to standard laparoscopic pyeloplasty.

Robot-assisted laparoscopic pyeloplasty: Multi-institutional experience in infants

INTRODUCTION Robot-assisted laparoscopic pyeloplasty (RALP) has been gaining acceptance among pediatric urologists. Over 300 have been described in the literature, but few studies have evaluated the role of RALP in infants alone. OBJECTIVE We sought to examine the operative experience and outcomes of RALP in a cohort of infants treated at multiple institutions across the United States. Our primary aim was to describe the safety and efficacy of RALP within this cohort. We recognize the challenges of performing minimally invasive surgery in small patients. In our paper, we address some technical considerations for the infant population. STUDY DESIGN This multi-centered observational study collected data on subjects one year of age or less who underwent RALP between April 2006 and July 2012 at five institutions. The primary outcome was resolution of hydronephrosis, and secondary outcomes included surgical time and complications. RESULTS A total of 60 patients (62 procedures) underwent RALP by six surgeons during the study period. All surgeons had > 5 years of experience beyond fellowship training. Mean surgical age was 7.3 months (SD ± 1.7 mo), 56 patients (95%) were diagnosed prenatally, and 59 patients (95%) had follow up imaging. Of these patients, 91% showed resolution or improvement of hydronephrosis. Two patients had recurrent obstruction and required additional surgery. Mean surgical time was 3 hours 52 minutes (SD ± 43 minutes). Seven (11%) patients reported intra-operative or immediate post-operative complications. DISCUSSION This series found a 91% success rate for reduction or resolution of hydronephrosis, and an 11% complication rate. This is equivalent to modern series comparing open pyeloplasty to pure laparoscopic and robotic-assisted laparoscopic pyeloplasty, which report success rates ranging from 70-96%, and complication rates ranging from 0-24% for open pyeloplasty. We lacked a standardized technique amongst institutions. This was not surprising since there are not established technical benchmarks for this surgery. However, we specified multiple technical considerations for this unique patient population. CONCLUSION The advantages of using robot-assistance to perform pyeloplasty in infants remain to be defined. This study cannot make that assessment due to small sample size. Nonetheless, this cohort is the largest robotic pyeloplasty series in infants to date. Seeing an excellent success rate and a low complication rate in this infant cohort is encouraging.

A review: the application of minimally invasive surgery to pediatric urology: upper urinary tract procedures.

This paper is one-half of a 2 part review on minimally-invasive procedures in pediatric urology. This article focuses on upper tract procedures, including complete nephrectomy, partial nephrectomy, pyeloplasty, and ureterocalicostomy. We note important articles on pure laparoscopic as well as robotic-assisted laparoscopic upper urinary tract surgeries, concentrating on their techniques and outcomes.

The role of laparoscopic surgery for urinary tract reconstruction in infants weighing less than 10 kg: A comparison with open surgery

PURPOSE To compare the outcome of laparoscopic urinary tract reconstruction (LUTR) in children weighing 10 kg or less with a weight-matched cohort undergoing open urinary tract reconstruction surgery (OUTR). MATERIALS AND METHODS We conducted a retrospective chart review of patients weighing 10 kg or less at the time of surgery who underwent open or laparoscopic pyeloplasty, transuretero-ureterostomy and ipsilateral uretero-ureterostomy between January 2000 and May 2007. The following information was recorded: body weight, age, sex, diagnosis, type of procedure, operative time, estimated blood loss, pre- and postoperative hemoglobin levels, length of hospitalization, length of follow up, use of drains and stents, intraoperative and postoperative analgesic requirement, need for readmission, subsequent procedures, costs, complications and reoperations. RESULTS There were 52 patients divided into two groups: LUTR (n=23) and OUTR (n=29). Median weight (range) and follow up was 6.2 kg (3.9-10) and 9 months and 6.5 kg (4.7-9.6) and 31 months for LUTR and OUTR, respectively. Mean operative time for LUTR (including cystoscopy and stent placement) was 237 min and for OUTR 128 min (P<0.01). There were no differences in blood loss, intra- or postoperative analgesic requirement, results or complications. Mean hospitalization time was shorter for LUTR than OUTR (2 and 3 days, respectively). There were no differences in hospital costs between the two groups. CONCLUSIONS Laparoscopic reconstructive surgery for congenital urological anomalies is safe and effective in small infants and can be performed with outcomes comparable to that of open surgery.

Infant robotic pyeloplasty: Comparison with an open cohort

OBJECTIVE To present our experience with infant pyeloplasty, comparing outcomes between robotic-assisted laparoscopic pyeloplasty (RALP) and open pyeloplasty (OP). MATERIALS AND METHODS A retrospective review was performed of all children <1 year of age who underwent unilateral dismembered pyeloplasty at a single pediatric institution since January 2007. Patients with standard laparoscopic pyeloplasty were excluded. Patient demographics, intraoperative details, narcotic usage, and complications were reviewed. RESULTS A total of 70 infants (51 boys and 19 girls) were identified, with nine RALP and 61 OP performed. Median age was 9.2 months (range, 3.7-11.9 months) for RALP and 4.1 months (range, 1.0-11.6 months) for OP (p = 0.005). Median weight was 8 kg (range, 5.8-10.9 kg) for RALP and 7 kg (range, 4-14 kg) for OP (p = 0.163). Median operative time was 115 min (range, 95-205 min) for RALP and 166 min (range, 79-300 min) for OP (p = 0.028). Median hospital stay was 1 day (range, 1-2 days) for RALP and 3 days (range, 1-7 days) for OP (p < 0.001). Median postoperative narcotic use of morphine equivalent was <0.01 mg/kg/day (range, 0-0.1 mg/kg/day) for RALP and 0.05 mg/kg/day (range, 0-2.2 mg/kg/day) for OP (p < 0.001). Median follow-up was 10 months (range, 7.2-17.8 months) for RALP and 43.6 months (3.4-73.8 months) for OP (p < 0.001). The success rate was 100% for RALP and 98% for OP. CONCLUSIONS Infant RALP was observed to be feasible and efficacious with shorter operative time, hospital stay, and narcotic utilization than OP.

The Impact of the Alexander Technique on Improving Posture and Surgical Ergonomics During Minimally Invasive Surgery: Pilot Study

PURPOSE One of the main ergonomic challenges during surgical procedures is surgeon posture. There have been reports of a high number of work related injuries in laparoscopic surgeons. The Alexander technique is a process of psychophysical reeducation of the body to improve postural balance and coordination, permitting movement with minimal strain and maximum ease. We evaluated the efficacy of the Alexander technique in improving posture and surgical ergonomics during minimally invasive surgery. MATERIALS AND METHODS We performed a prospective cohort study in which subjects served as their own controls. Informed consent was obtained. Before Alexander technique instruction/intervention subjects underwent assessment of postural coordination and basic laparoscopic skills. All subjects were educated about the Alexander technique and underwent post-instruction/intervention assessment of posture and laparoscopic skills. Subjective and objective data obtained before and after instruction/intervention were tabulated and analyzed for statistical significance. RESULTS All 7 subjects completed the study. Subjects showed improved ergonomics and improved ability to complete FLS™ as well as subjective improvement in overall posture. CONCLUSIONS The Alexander technique training program resulted in a significant improvement in posture. Improved surgical ergonomics, endurance and posture decrease surgical fatigue and the incidence of repetitive stress injuries to laparoscopic surgeons. Further studies of the influence of the Alexander technique on surgical posture, minimally invasive surgery ergonomics and open surgical techniques are warranted to explore and validate the benefits for surgeons.

Urinary NGAL Levels Correlate with Differential Renal Function in Patients with Ureteropelvic Junction Obstruction Undergoing Pyeloplasty

PURPOSE Recent investigations described the use of NGAL, a sensitive biomarker for kidney injury, in the setting of ureteropelvic junction obstruction. We prospectively evaluated urinary NGAL levels in the affected renal pelvis and bladder of children with ureteropelvic junction obstruction undergoing unilateral dismembered pyeloplasty. Our hypothesis was that higher NGAL in the kidney and bladder would correlate with decreased ipsilateral differential function. MATERIALS AND METHODS We performed a prospective cohort study in patients treated with unilateral dismembered pyeloplasty from 2010 to 2012. Urine was obtained intraoperatively from the bladder and obstructed renal pelvis. A control population of unaffected children was recruited to provide a voided bladder specimen. Bladder NGAL levels were compared between the study and control populations. We tested our study hypothesis by correlating bladder and renal pelvic NGAL levels with the differential renal function of the affected kidney. RESULTS A total of 61 patients with a median age at surgery of 1.62 years (range 0.12 to 18.7) were enrolled in the study. Median bladder NGAL was 18.6 ng/mg (range 1.4-1,650.8) and median renal pelvic NGAL was 26.2 ng/mg (range 1.2-18,034.5, p = 0.004). Median bladder NGAL was significantly higher than in controls (p = 0.004). The correlation of bladder and renal pelvic NGAL with differential renal function was r = -0.359 (p = 0.004) and r = -0.383 (p = 0.002), respectively. CONCLUSIONS Bladder NGAL is increased in children with ureteropelvic junction obstruction. Renal pelvic and bladder normalized urinary NGAL levels correlate inversely with the relative function of the affected kidney in cases of unilateral ureteropelvic junction obstruction.

A Review: The Application of Minimally Invasive Surgery to Pediatric Urology: Lower Urinary Tract Reconstructive Procedures

This paper is one-half of a 2 part review on minimally-invasive procedures in pediatric urology. This article focuses on lower tract procedures, including ureteroureterostomy, anti-reflux surgeries, creation of continent catheterizable channels, and augmentation cystoplasty. We note important articles on pure laparoscopic as well as robotic-assisted laparoscopic lower urinary tract surgeries, concentrating on their techniques and outcomes.

A robotic-assisted laparoscopic approach for pediatric renal cell carcinoma allows for both nephron-sparing surgery and extended lymph node dissection ☆ ☆☆ ★

Partial nephrectomy has been previously reported as safe and effective in appropriately selected children with renal cell carcinoma (RCC). However, there are limited reports of laparoscopic or robotic partial nephrectomy for oncologic surgery in children. Additionally, nodal involvement is common in pediatric RCC, and may present even with small primary tumors. Also, it is suggested that lymph node dissection may provide therapeutic benefit. We present a case of pediatric RCC and demonstrate how the risk of nodal involvement may impact the surgical approach. Robotic-assisted laparoscopy can permit excellent exposure for an oncologically-sound resection, in this case a partial nephrectomy, as well as an extended lymph node dissection.

Ninety-day perioperative complications of pediatric robotic urological surgery: A multi-institutional study.

BACKGROUND Robotic technology is the newest tool in the armamentarium for minimally invasive surgery. Individual centers have reported on both the outcomes and complications associated with this technology, but the numbers in these studies remain small, and it has been difficult to extrapolate meaningful information. OBJECTIVES The intention was to evaluate a large cohort of pediatric robotic patients through a multi-center database in order to determine the frequency and types of complications associated with robotic surgery for pediatric reconstructive and ablative procedures in the United States. STUDY DESIGN After institutional review board approvals at the participating centers, data were retrospectively collected (2007-2011) by each institute and entered into a RedCap(®) database. Available demographic and complication data that were assigned Clavien grading scores were analyzed. RESULTS From a cohort of 858 patients (880 RAL procedures), Grade IIIa and Grade IIIb complications were seen in 41 (4.8%); and one patient (0.1%) had a grade IVa complication. Intraoperative visceral injuries secondary to robotic instrument exchange and traction injury were seen in four (0.5%) patients, with subsequent conversion to an open procedure. Grade I and II complications were seen in 59 (6.9%) and 70 (8.2%) patients, respectively; they were all managed conservatively. A total of 14 (1.6%) were converted to an open or pure laparoscopic procedure, of which, 12 (86%) were secondary to mechanical challenges. DISCUSSION It is believed that this study represents the largest and most comprehensive description of pediatric RAL urological complications to date. The results demonstrate a 4.7% rate of Clavien Grade IIIa and Grade IIIb complications in a total of 880 cases. While small numbers make it difficult to draw conclusions regarding the most complex reconstructive cases (bladder diverticulectomy, bladder neck revision, etc.), the data on the more commonly performed procedures, such as the RAL pyeloplasty and ureteral reimplantation, are robust and more likely represent the true complication rate for these procedures when performed by highly experienced robotic surgeons. CONCLUSION Pediatric robotic urologic procedures are technically feasible and safe. The overall 90-day complication rate is similar to reports of laparoscopic and open surgical procedures. COMPLICATIONS n (%) Life threatening (IVa): 1 (0.1%) Requiring radiologic and or surgical intervention (IIIa and IIIb): 41 (4.8%) Secondary to robotic system: 4 (0.5%) Mechanical failure leading to conversion: 14 (1.6%).