Robotic Assisted vs. Pure Laparoscopic Surgery in Pediatric Urology
Daniel B. Herz, M.D., Paul A. Merguerian, MD.
Children's Hospital at Dartmouth / Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
BACKGROUND: Advances in pediatric robotic assisted laparoscopy has allowed widespread application of robotics to multiple pediatric urological procedures traditionally performed by pure laparoscopy. This report is a comparison of several laparoscopic pediatric urologic procedures performed by pure laparoscopy and robotic assisted laparoscopy.
METHODS: Over 4-year period 38 pure (LAP) and 34 robotic assisted (RAL) laparoscopic surgeries were performed by 2 pediatric urologists. Procedures were Dismembered Pyeloplasty, Ureteroneocystostomy, Orchidopexy, Ureteroureterostomy, Urachal resection, Pyeloureterostomy, Appendicovesicostomy, Appendicostomy, Nephrectomy and Heminephroureterectomy. Mean operative time, hospital stay, surgical and technical success, and complications were recorded per case for each group. RAL procedures were performed with both 5 and 8mm instruments and LAP procedures with 5 and 10mm instruments. A DJ ureteral stent was placed in all Pyeloplasties, and all RAL Ureteroneocystostomies. All surgeries were transperitoneal. Success was defined as both technical as well as surgical, which, depending on the procedure, was defined as radiographic absence of obstruction or vesicoureteral reflux; resolution of symptoms or UTI; or testes with a scrotal position. Follow-up was at least 12 months in both groups.
RESULTS: Mean age for the RAL was 5.25 and 4.75 years for LAP, respectively. Overall technical success for RAL and pure LAP was 100%. There were no open conversions. Surgical success was higher overall for RAL compared to LAP (88% and 83% respectively). Hospital stay was comparable between the RAL and LAP groups. Compared to LAP, mean operative time was shorter for RAL Pyeloplasty, Appendicostomy, Appedicovesicostomy, Heminephroureterectomy, Ureteroureterostomy and Pyeloureterostomy; but longer for RAL Ureteroneocystostomy, Orchidopexy, Urachal resection, and Simple Nephrectomy. The presence of the robot made inguinoscrotal tunneling and scrotal suturing during laparoscopic orchidopexy more technically challenging. Complications included omentum herniation (n=1: RAL), bleeding (n=1: LAP), urinary leak (n=1: LAP), umbilical port infection (n=1: RAL).
CONCLUSIONS: Both robotic assisted and pure laparoscopy are safe and effective. For extirpative procedures and Orchidopexy there was no benefit to robotic assistance. However, there was benefit of robotic assistance if intracorporeal suturing or preserving one renal moiety was needed.