Current Trends in Pediatric Minimally Invasive Urologic Surgery [notes]

Paper by D.Lee, P.Kim, C.Koh.

[Source Link at NIH] – extensive quotes

[freedictionary]- definitions reference

Abstract:

Laparoscopic & Robot surgery appears to lead to host of benefits, such as shorter hospital stays, decreased pain med requirements, improved cosmesis. It appears to be safe and effective for children for a wide range of ablative (surgical removal of tissue) and reconstructive procedures.

Conventional laparoscopic is effective for ablative procedures, robotic surgery is better for reconstructive, because of advanced suturing and dissection.

Intro:

This is a review of literature on state of laparoscopic [LS] & robotic surgery  in pediatric urology.

Widespread adoption of LS surgery for pediatric urology hindered by limitations in equipment & learning curve.

Robot-assisted [RA]

Materials & Methods:

Pubmed used to search for articles.

1. Adrenalectomy

Surgery to remove adrenal gland (s).

LS adrenalectomy widely used in adults; preferred over open for benign lesions because of less blood loss, painkillers, hospital stays. Better cosmesis (bodily beauty). Similar outcomes to open surgery [OS] in terms of recurrence rates, survival.

Pediatrics seem similar, but majority of pediatric adrenal lesions are malignant: most common is neuroblastoma (type of cancer formed from nerve cells). This may have led to delays in adapting techniques.

retroperitoneal [RP] & transperitoneal[TP] (relating to behind/across peritoneum (membrane that lines the abdominal cavity)) approaches have been reported. Length of hospital stay, time to post-operative feeding, and chemotherapy were noted to be shorter than OS.

RA LS adrenalectomy have been performed successfully in adults. Benefits: increased magnification & range of movement than conventional laparoscopy, which helps dissection along major vessels and organs. Also helps with isolation of adrenal gland. Not yet described for children

2. Nephrectomy

“The most common indication [symptom] for laparoscopic nephrectomy in pediatric population is a nonfuctional kidney due to obstructive uropathy, stone disease, vesicoureteral reflux, or multicystic dysplastic kidney” (81).

Both RP & TP approaches have been described. TP approach offers larger working space. Recommended when working bilaterally or removing multicystic dysplastic kidney. Both approaches safe; similar outcomes and complication rates. Common reported complications: vascular injuries, bowel injuries, hematomas, urinomas, port side hernias.

El-Ghoneimi et al.: 100 LS nephrectomy via RP approach with no open conversions. Meta study shows longer mean operative time for LS group, but shorter hospital stay time, lower qualitative analgesic demands than OS.

LS surgery for pediatric renal neoplasms (new/abnormal tissue growth, characteristic of cancer) is controversial. No consensus for tumor size appropriate for surgery in children. studies needed to determine safety/efficacy .

“Laparo-endoscopic single-site (LESS) nephrectomy for benign renal disease in children is the single-port modification of laparoscopic nephrectomy” (81) Surgery basically scar free through incision in umbilicus. Records exist for successful surgery. Associated with improved cosmesis and shorter recovery than standard LS nephrectomy.

RA LS nephrectomy can be done in TP or RP approach, but RP approach in infants difficult because of size.  Ablative procedures don’t require reconstructive capabilities available in robots, but these may be good cases for learning.

3. Partial nephrectomy and heminephrectomy

Most common reason for these procedures in pediatric patients is nonfunctioning “upper- or lower-pole moiety (each of two parts into which a thing can be divided) in a duplicated system associated with ureterocele, ectopic ureter, or vesicoureteral reflux. Duplicated systems in children have well-defined anatomic & vascular planes between the upper and lower systems, which decrease the risk of injury to the remaining moiety” (link is mine). Both TP or RP approaches may be used for LS partial nephrectomy. Benefits: improved visualization f/ magnification, minimal blood loss, rapid recovery & excellent cosmesis

In comparison, LS group have shorter hospital stay, lower narcotic requirements. A urinoma was noted as complication.

Complications noted for infants undergoing LS heminephrectomy (excision of half of kidney). Complete loss of fn of remaining ipsilateral(belong to same side of body) moiety in 2/5 infant patients. Unknown whether this is because of LS RP approach not having enough room as TP approach, or because infants more susceptible to ischemic (blood supply) changes induced by retropneumoperitoneum(?). TP approach probably better for infants.

RA LS partial nephrectomy can be done TP and RP approaches. benefits over LS surgery not proven except when “bladder reconstruction and ureteral reimplantation of remaining moiety are necessary after ureterectomy [excision of ureter].” Records of 9 children that underwent procedure exist. Remaining renal moiety normal after procedure. minimal complication, though one patient reported urinoma.

Overall, TP and RP approaches to LS partial nephrectomy appear safe & effective. Similar operative times as OS. Better w/ regards to post-op pain, hospital stay & cosmesis. RA LS partial nephrectomy appears safe & effect, and advantages of robot seen for cases involving significant reconstruction.

4. Pyeloplasty (Plastic or reconstructive surgery of the pelvis of the kidney to correct an obstruction.)

“Ureteropelvic junction obstruction (UPJO) is the most common obstructive uropathy found in children, and the gold standard for the treatement of UPJO is open pyeloplasty with success rates exceeding 90%” (83). LS pyeloplasty has similar success rates as OS.

TP and RP approaches have been used. TP provides larger working space, may facilitate suturing. RP may make dissection easier, and reduce risk of intra-abdominal injury. A study reports TP LS pyeloplasty safe & effective in all age groups. Another study reports 96.5% success, 1 OS conversion for 107 surgeries.

Outcomes from RP approach seems similar to TP approach. A study reports 22 RP LS pyeloplasticies. 4 require OS conversion because anastomosis (operative union of two structures) was difficult. LS has shorter hospital stay, shorter time to cessation of pain meds, but longer operative time vs OS. Urine leakage noted in both groups.

LS pyeloplasty appears to be associated with higher rate of secondary procedures. reoperative intervention and redo rate were higher in LS group than OS.

RA LS pyeloplasty is the most common procedure performed with the Da Vinci robot. May potentially decrease the higher rate of secondary procedures seen with conventional LS pyeloplasties. Several studies show LA LS is safe and effective; success rate of 95%, similar to OS. Complication rate similar to OS. Robot group has shorter hospital stay, lower narcotic requirement; mean operative time is higher, generally. The operative times became shorter than OS with experience.

5. Ureteral reimplantation (fix tubes that connect bladder to kidneys)

“Open ureterovesical reimplantation surgery has a long, favorable history in children with vesicoureteral reflux [condition where urine flows from bladder back into kidneys] with success rates exceeding 95% and with minimal associated morbidity” LS also appears safe and effective, especially using Lich-Gregoir extravesical technique. Benefits: shorter hospital saty, reduction in post-op pain meds requirements, and improved cosmesis compared to OS. In a report regarding 47 children, 3 ureteral injuries reported. Stress importance of proper patient selection. Younger than 4 and presence of concomitant ureteroceles (ballooning of lower end of ureter into bladder) or megaureters (congenital dilation of the ureter) that require tapering may be possible contraindications( indicate inadvisability of medical treatment) for LS.

Transvesical LS ureteral reimplantation, where bladder is insufflated [to deliver air or gas under pressure to a cavity or chamber of the body] w/CO2 and “:ureteral reimplantation is performed by using a combination of intravesical cystoscopy and laparoscopy, has been reported with mixed results.”. A report indicated 47% success with Gil-Vernet technique and 83% with Cohen technique. Operative times nearly twice of standard open techniques. Recently, modified pneumovesicoscopic approach used, where LS “is placed transabdominally rather than transurethrally.”. In a study with 16 children, Cohen cross-trigonal ureteral reimplantation by use of CO2 pneumovesicum had success rate of 96%. A report of cross-trigonal reimplantation had success rate of 92.6%, wile Glenn-Anderson reimplantation had 80% success.

Robots may improve outcomes. increased magnification and EndoWrist(tm) instruments may help overcome learning curve of advanced LS skills.  Also confers improved dexterity. May be possible to utilize similar techniques as those of open surgery.

Extravesical approach is the most commonly used approach to perform RA LS ureteral reimplantation. Similar to OS and LS Lich-Gregoir techniques.  Robot surgery success 97.6%, minimal complications. RA LS ureteral reimplantation has been done successfully via pneumovesicoscopic approach and an intravesical cross-trigonal technique.  Procedure not good for bladders smaller than 130ml, because of space limits. The approach is challenging, but offers good visibility

6. Lower Urinary tract reconstruction

“Slow, but steady, progress in the area of minimally invasive lower urinary tract reconstruction has been made over the past 2 decades”. Steep learning curve and high potential for complications when working with bowels. LS Mitrofanoff appendicovesicostomy (transference of appendix to use as conduit for urinary diversion from bladder to skin to make route for insertion of catheter) done successfully through both LS and RA LS approaches. RA surgery appears to be helpful in improving “continence  (ability to retain urine/feces until proper discharge) of the appendicovesicostomy anastomosis (seen earlier. formation of connection between two distinct structures)”. comparing LS antegrade continence enemas vs OS found no differences in operative times and complication rates. LS group had less post-op pain med reqs, and shorter hospital stays.

Use of LS for bladder augmentation (enterocystoplasty) in patients with neurogenic (originating in, starting from, caused by nervous system) bladders using stomach segment reported in 1995.  There are reports of LS surgery through lower midline or Pfannenstiel incision (where LS bladder augmentation were successfully performed with adequate postop capacity).

“Adoption of LS techniques for bladder augmentation in children has been slow bc of technical complexity of the procedure with many patients having history of previous abdominal surgery that hinder LS approach.” Risk of ventriculoperitoneal shunt (surgically created passageway between cerebral ventricle and peritoneum for draining of excess cerebrospinal fluid from brain in hydrocephalus) complications with intraperitoneal (within peritoneal cavity) bowel leakage may be significant

RA LS may have a future.

Conclusions

literature shows LS and RA urologic procedures are safe and effective in pediatric population. operative times should decrease with experience and technique. “Conventional LS will likely become standard of care in ablative procedures in pediatric urology, such as LS nephrectomy, whereas RA LS will be preferred for minimally invasive approach to reconstructive procedures such as pyeloplasty, which requires precise suturing.” Trend towards scarless surgery may continue as parents seek minimally invasive options. Future studies needed for long-term safety, efficacy.

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