“Pediatric laparoscopic pyeloplasty: Lessons learned from the first 52 cases.”
Chacko, J. K., L. A. Piaggio, et al. (2009).
Journal of Endourology 23(8): 1307-1311.
Background and Purpose: The use of laparoscopy for pediatric pyeloplasty is increasing. We review our experience with our first 50 cases and describe the main technical points learned during this experience. Patients and Methods: We retrospectively reviewed the charts of all patients who underwent laparoscopic pyeloplasties (LP) over a 4-year period (January 2004 to January 2008) at our institution. Patient demographics, operative details, hospital stay, outcomes, and complications were examined. Results: Fifty-two patients underwent LP from for primary repair of ureteropelvic junction obstruction (UPJO). Thirty-six male and 16 female were operated on at an average age and weight (range) of 51.8 months (3 weeks to 216 months) and 20kg (3.9-74.2kg), respectively. Intraoperatively, 47/52 (90%) underwent retrograde ureteropyelography (RUPG), and 51/52 (98%) had a ureteral stent placed during surgery. Nine crossing vessels (17%) were identified at the time of surgery. The anastomoses were performed with a running absorbable suture. Operative time was 248min (range 120-693min). The average hospital stay was 3 days (range 1-7). A bladder catheter usually remained indwelling for 2 days and a perirenal drain for 3 days; they were removed before hospital discharge. The stent remained in place on average 39 days (range 11-127d) and was removed with the patient under a brief general anesthetic. Anastomotic patency was seen in 51/52 (98%) patients determined by improvement on postoperative renal ultrasonography and/or resolution of symptoms. Mean follow-up was 20 months (range 3-50 mos). Complications included recurrence of UPJO necessitating redo LP (1), dislodgement of a nephrostomy (1), stent replacement (1), ileus (2), and vascular injuries treated laparoscopically (2). No patients needed conversion to open surgery. Conclusion: LP has supplanted open pyeloplasty at our institution. We have noted improved success by performing RUPG to define the anatomy and stent placement at the beginning of the case, using purple 5-0 or 6-0 poliglecaprone suture for the anastomosis and a 5-mm wide-angle lens for visualization. We found no disadvantages for the transperitoneal approach, although we find it necessary to leave a drain. With the increased use of LP in pediatric urology, we hope these observations from our experience will help improve the learning curve for others making this transition. © Copyright 2009, Mary Ann Liebert, Inc. 2009.
“Laparoscopic training–the guarantee of a future in pediatric surgery.”
Drǎghici, I., L. Drǎghici, et al. (2009).
Trainingul laparoscopic–certitudinea unui viitor în chirurgia pediatricǎ. 104(3): 255-258.
Laparoscopy is considered today the highlight of modern surgery, the forerunner of the fascinating world of video and robotic surgery, both of them derived from the sophisticated areas of aeronautic industry. Remarkably, Romanian specialists keep up with the pace of worldwide technological developments, assimilating one by one each and every video endoscopic procedure. In the early 90s, the Romanian laparos-copic school was founded with the contribution of many important personalities; their activities and achievements have been an inspiration for the following generation of laparoscopic surgeons. In this last decade, the newest branch of laparoscopic surgery in our country, pediatric laparoscopy, managed to evolve from its “shy” beginnings to become an important method of improving the quality of surgical procedures, to the benefit of our “small patients”. The purpose of this article is to encourage and promote minimally invasive video endoscopic surgery training, emphasizing its crucial role in the education and professional development of the next generation of pediatric surgeons, and not only. The modem concept of laparoscopic training includes experimental scientific practices, as well as the newest technical acquisitions such as virtual reality video-electronic simulation.
“Pediatric robot-assisted laparoscopic varicocelectomy.”
Hidalgo-Tamola, J., M. D. Sorensen, et al. (2009).
Journal of Endourology 23(8): 1297-1300.
Purpose: We determined the feasibility and safety of robot-assisted laparoscopic varicocelectomy (RALV) in the pediatric population compared with laparoscopic varicocelectomy (LV). Patients and Methods: We identified all patients who underwent RALV since April of 2006. For each case, we selected two age-matched controls who underwent LV and compared the groups in terms of operative times, postoperative complications, and hospital charges. Statistics were determined using the Student t test and the Fisher exact test. Results: Four patients underwent RALV with a mean age of 15.3 years (standard deviation 1.3). All varicoceles were left-sided. Two patients had testicular size discrepancy at presentation (mean 24%). Mean operative times were 112 minutes for RALV vs 73 minutes for LV (P=0.02). No intraoperative or postoperative complications were experienced in the RALV group. The mean total hospital charge-including facility, equipment, anesthesiology, and recovery room fees, but excluding surgeon’s professional fees-was significantly higher for the robot-assisted group ($15,800 vs $8,600, P=0.0005). Conclusion: We report the first RALV in a pediatric patient population. We demonstrate that it is technically feasible with no intraoperative complications. It remains to be seen whether RALV is cost effective over LV. © Copyright 2009, Mary Ann Liebert, Inc. 2009.
“14-Gauge Angiocatheter: The Assist Port.”
Hotaling, J. M., S. Shear, et al. (2009).
J Laparoendosc Adv Surg Tech A.
Abstract Introduction: Minimally invasive techniques have emerged as the standard of care for some procedures in pediatric urology. In an effort to minimize required ports for robotic-assisted laparoscopic (RAL) surgeries in children, we describe in this article a novel technique for using a 14-gauge (G) angiocatheter as an assist port in concert with various readily available cystoscopic equipment. Materials and Methods: After the insertion of robotic ports and docking, the da Vinci((R)) Surgical System (Intuitive Surgical, Sunnyvale, CA), using a 14-G angiocatheter, was placed through the abdominal wall under direct vision. The 14-G angiocatheter was then used to facilitate stent placement, provide a port for semiflexible cystoscopic graspers, and to evacuate cautery smoke. At the end of each case, the 14-G angiocatheter was removed under direct vision prior to undocking the robot. Results: A 14-G angiocatheter was used as an assist port in 17 RAL urologic procedures (16 RAL dismembered pyeloplasties and 1 robotic orchiopexy). No complications occurred and the angiocatheter’s use avoided the placement of 3- or 5-mm additional assist ports. Conclusions: The 14-G angiocath technique uses existing equipment, requires no closure, and can be placed anywhere on the abdominal wall. It allows the RAL dismembered pyeloplasty to be performed with only two instrument ports and no additional trocar for assistance. This is the first described method in the urologic literature of using a 14-G angiocatheter to maximize operative assistance while minimizing port placement in pediatric RAL surgery.
“Pediatric urolithiasis.”
Mandeville, J. A. and C. P. Nelson (2009).
Current Opinion in Urology 19(4): 419-423.
PURPOSE OF REVIEW: We review the recent literature on pediatric urolithiasis and present up-to-date findings on epidemiology, diagnosis, and medical and surgical management. RECENT FINDINGS: There are surprisingly few reliable data on pediatric urolithiasis incidence, but widespread anecdotal and single-center reports suggest that more children with stones are being seen. The contamination of Chinese infant formula with melamine caused urolithiasis and other renal problems in hundreds of thousands of infants in the region, underlining the role of environmental factors in urolithiasis. Efforts continue to determine normal metabolic parameters in children, but have been hampered by variations among regions, races, and ethnicities. The Bonn Risk Index may prove to be a useful tool for assessing risk of urolithiasis in children. Children with recurrent urolithiasis are more likely to have detectable metabolic abnormalities. Surgical approaches to urolithiasis in children continue to evolve, with robotic-assisted laparoscopy being perhaps the most significant new technique. Finally, clinicians and radiologists must be aware of the potential for dextranomer/hyaluronic acid (Deflux) implants to mimic distal ureteral stones on computed tomography (CT) scan. SUMMARY: Pediatric urolithiasis is an expanding field, due in part to the apparent increase in cases. Research continues, seeking to refine the appropriate diagnostic and therapeutic approaches in these unfortunate children. © 2009 Lippincott Williams & Wilkins, Inc.
“Robotic Surgery in Small Children: Is There Room for This?”
Meehan, J. J. (2009).
J Laparoendosc Adv Surg Tech A.
Abstract Some pediatric surgeons may be reluctant to use robotic surgery for small patients because the only available surgical robot might seem too large for smaller patients. However, we have found this concern invalid. We have been successful in a wide variety of Minimally Invasive Surgery procedures using robotics for general surgery applications in small children. However, several technical issues must be considered in order to optimize this technology for these children. In this article, we present a retrospective review of 45 patients of less than 10 kg who underwent robotic surgery and discuss the adjustments we made in order to adapt this technology to our small patients in a wide variety of general surgical procedures.