Robotassisted Laparoscopic Pyeloplasty

Laparoscopic pyeloplasty requires expertise and ability with intracorporeal suturing. Despite improvements in surgical instrumentation, laparoscopic pyeloplasty remains a demanding procedure that requires a long learning curve.

The recent introduction of robotics in the field of minimally invasive surgery may facilitate this procedure and allow for more widespread implementation by surgeons of varying skill levels. The goal of advance robotic systems is to improve operative technique and simplify suturing during reconstructive procedures.

Initially, two robotic systems were available: the Zeus™ b and the da Vinci™. Animal studies comparing the two systems demonstrated a shorter learning curve and operative

TABLE 4 ■ Laparoscopic Pyeloplasties in Pediatric Series of Patients

Age

Mean OR

Conversion

Mean HS

Mean FU

Success

Authors

Units

(range)

Access

Procedure

time (range)

(%)

(range)

(range)

(%)

El Ghoneimi et al. (35)

22

S

Retroperitoneal

AH dismembered

22S

(1S.1)

2.5

12.7

100

(1.7-17)

pyeloplasty

(170-300)

(2-4)

(2-36)

Tan (13)

1S

1.4

Transperitoneal

AH dismembered

S9

S7

(0.25-10)

pyeloplasty

Yeung et al. (14)

13

2.7

Retroperitoneal

AH dismembered

143

(15.3)

100

(0.25-10)

pyeloplasty

(103-235)

Abbreviations: AH,Anderson-Hynes; OR, operating room; HS, hospital stay; FU, follow-up.

Abbreviations: AH,Anderson-Hynes; OR, operating room; HS, hospital stay; FU, follow-up.

The small caliber of a child's ureter makes pyeloplasty a difficult procedure.

Available series of laparoscopic dismembered pyeloplasty showed excellent results, thus confirming the feasibility and safety of this procedure in this patient population.

aIntuitive Surgical, Inc., Mountain View, CA. bComputer Motion, Santa Barbara, CA.

Although suturing for the inexperienced is easier with the robot, laparoscopic knowledge is still required and the use of the robot involves a steep learning curve as well.

Laparoscopic pyeloplasty has been used in the presence of crossing vessels, highgrade hydronephrosis, and poor renal function as another minimally invasive alternative. The laparoscopic ability to directly identify crossing vessels and reduce a large renal pelvis recapitulates the advantages of the open approach.

times with the da Vinci system, which is now the only commercially available robotic system (37). These systems may enable the surgeon inexperienced with laparoscopic suturing to perform reconstructive procedures with greater ease. Experimental data showing that intracor-poreal suturing and dexterity tasks are learned quicker using robot-assisted than manual laparoscopy indicated the robot as an ideal choice during reconstructive surgery (38).

Gettman et al. (39) confirmed the feasibility and safety of robot-assisted dismembered pyeloplasty in a small number of patients. Mean suturing time was 62.4 minutes and overall operating time 138.8 minutes, shorter than those reported in conventional laparoscopic pyeloplasty series. A comparison of conventional versus robotassisted laparoscopic pyeloplasty, both dismembered and nondismembered, performed in the same institution confirmed shorter operating times in the robotic group (40). Although the robotic system was favorable for suturing; some aspects of the procedure that require gross rather than precise movements, e.g., the reflection of the bowel or the counter traction during dissection, were more difficult with the robotic arms.

Although suturing for the inexperienced is easier with the robot, laparoscopic knowledge is still required and the use of the robot involves a steep learning curve as well.

Proper trocar placement is necessary to prevent mechanical interference between the robotic arms. Due to the lack of tactile feedback, the surgeon must develop an intuition about suture tension to prevent suture breakage and tissue strangulation during knot-tightening. As a result, laparoscopic surgeons experienced with intracorporeal suturing may not find the robot helpful. Finally investment and running costs are factors that must be considered.

A larger number of patients with longer follow-up must be evaluated to determine whether pyeloplasty performed with robotic assistance have equally good functional results as those obtained with conventional laparoscopic pyeloplasty.

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