Robotic versus open ureteral reimplantation for distal ureter benign stricture disease.
Spencer I. Kozinn, MD, Jessica Mandeville, MD, Karim Hamawy, MD, Andrea Sorcini, MD, David Canes, MD, John A. Libertino, MD, Ali Moinzadeh, MD.
Lahey Clinic Medical Center, Burlington, MA, USA.
BACKGROUND: Minimally invasive techniques are currently employed for numerous urologic procedures given decreased patient morbidity and equivalent outcomes to open surgery. There is however a relative paucity of data as related to robotic assisted (RA) distal ureteral reconstruction for benign stricture disease. We sought to compare the efficacy, cost, and functional outcomes of open versus RA distal ureteral reconstruction at our institution.
METHODS: We retrospectively identified 9 consecutive patients undergoing 10 RA reconstructive procedures since 2005. Twenty four patients undergoing open distal ureter reconstruction over the same period were identified and 10 age-matched controls used for comparison. Overall cost was calculated by factoring in OR time, instrument and robot costs, ICU care, and length of stay. Demographic, operative, and cost parameters were compared using Student T-test , Wilcoxon Rank Sum, or Fischer’s exact test as appropriate.
RESULTS: SEE TABLE 1.
Etiology of the strictures in both groups included stone disease (n=7, 35%) and iatrogenic ureteral injury during prior abdominopelvic surgery (n=13, 65%). All robotic procedures were completed in a minimally invasive fashion without conversion to open surgery. No Intraoperative complications were noted for either group. Six neocystotomies, 3 psoas hitches, and one Boari flap were completed in an open fashion. Four neocystotomies, 4 psoas hitches, and 2 Boari flaps were performed in the RA group.
Estimated blood loss (EBL) and length of hospital stay (LOS) were significantly shorter in the robotic group. One patient in the open group required a blood transfusion. There was a trend toward increased operative time and higher BMI in the robotic surgery patients. None of the patients in either category had clinical or radiological evidence of recurrent stricture disease. The mean direct hospital cost of the procedure robotically ($10,328) was significantly higher than the open group ($5,841).
CONCLUSION: Our series represents one of the largest single institution experiences with robot assisted ureteral reimplants published to date. In experienced hands, RA ureteral reconstruction appears to be an alternative to open surgery with excellent intermediate term follow up. Increased cost and surgical expertise may be the main limitations of the robotic approach.
|Open (n=10)||RA (n=10)||p-value|
|Age (range)||53.7 (40-63)||51.3 (33-63)||0.589|
|Operative Time (min)||270.0±182.8||339.5±48.4||0.316|
|LOS (POD discharge)||5.1±2.6||2.8±1.2||0.010|
|Median follow-up (mos)||16 (95% CI 4-22)||6.5 (95% CI 2-38)||1.000|