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A Nine-Year experience on Robotic-Assisted Laparoscopic Pyeloplasty for Children and Young Adults
Courtney K. Rowe, M.D., Brian J. Minnillo, M.D., Jose Cruz, M.D., Rogerio H. Sayao, M.D., Alan B. Retik, M.D., Hiep T. Nguyen, M.D.
Children's Hospital Boston, Boston, MA

Purpose: Open dismembered pyeloplasty is the traditional surgical approach for treating ureteropelvic junction obstruction in pediatric patients with reported overall success rates from 90-98%. Robotic-assisted laparoscopic pyeloplasty (RALP) has become one of the most common robotic procedures performed in children. Despite some early success in pediatric robotic surgery, the field continues to evolve while technical and surgical challenges remain. The literature is brief on long-term experience and clinical outcomes data. Our purpose is to present a large series of pediatric robotic-assisted pyeloplasty cases with an adequate follow-up period. The goal is not to compare open surgery to robotic surgery, but to assess our learning experience and clinical outcomes through a variety of measures.
Methods: We performed a retrospective review of 155 patients (mean age 10 years, range 0.7-24, 112 (72%) male) who underwent RALP from March 2000 to September 2009. No patients were excluded from analysis. Preoperatively all patients were evaluated with renal US and/or Mag3 renography and indications for surgical correction were reduced relative renal function and prolonged drainage or symptoms in older children. Two surgeons performed all procedures. Demographic and perioperative data were collected. Operative times, hospital stay, days with foley catheter, follow up time, clinical outcomes, and complications (intra/postoperative) were recorded. Success was defined as symptomatic improvement, improved hydronephrosis, and/or better drainage on postoperative imaging (if performed).
Results: The mean operative time was 204 minutes (range 88-512), hospital stay 1.95 days (range 1-9) and estimated blood loss 15cc (5-50). There were 17 (10.9%) postoperative complications (12 (7.7%) Clavien grade III and 5 (3.2%) Clavien grade I-II) and overall 5 (3.2%) requiring reoperative pyeloplasty (2 missed crossing vessel, 2 recurrent stenosis, 1 retroperitoneal fibrosis). At a mean follow up period of 31.7 months (range 3-53), there was 96.8% (150) primary success with improved (85%) or stable (11%) hydronephrosis on US.
Conclusions: Laparoscopic reconstructive procedures in children can be technically demanding and pose a learning curve for the novice surgeon. We previously published (Lee et al.) a one to one comparison demonstrating safety and efficacy in the RALP versus open pyeloplasty. The current series illustrates how our experience has improved with the adoption of a robotic training program in 2006 as well as increased nursing staff/resident training within the confines of our pediatric urology fellowship program.


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