Columbus, OH - January 2016
Laparoscopic surgeries are complex in pediatric patients with duplex renal anomaly (DRA). The amount of suturing involved and other factors most often cause urologists to choose conventional open surgery. A minimally invasive approach, though, could reduce patient pain and recovery time.
A recent study led by urologists at Nationwide Children’s Hospital has found that robot-assisted laparoscopic (RAL) surgery is feasible for most duplex renal anomaly patients and produces good outcomes. In some cases, it may be the preferred option. But the study’s authors caution that there are still reasons why surgeons may prefer an open procedure, especially in children who need extensive ureteral tapering during a common sheath ureteral implant.
“If you know how to do robotics, are an established robotic surgeon and have a good candidate, the laparoscopic procedure is a good one,” says Daniel Herz, MD, a member of the Section of Urology at Nationwide Children’s, director of Robot-Assisted Laparoscopic Surgery at the hospital and lead author of the study. “But I would caution the young robotic surgeon that certain procedures are not the type of RAL surgery that you want to cut your teeth on.”
The study retrospectively analyzed 47 children with DRA who had a total of 45 RAL surgeries. Heminephrectomy was performed in 20, ureteroureterostomy in 14, and common sheath ureteral implant (ureteroneocystostomy) with or without ureteral tapering in 13. All procedures were performed with the da Vinci® Surgical System.
The mean case time for RAL heminephrectomy was 209 minutes (range 169-330 minutes). Four of the 20 children developed vesicoureteral reflux (VUR) after the procedures; two of those VUR cases resolved spontaneously, and the two others required surgery. The overall success rates, operation times and expected complications are comparable to open heminephrectomy.
The mean surgery time for RAL ureteroureterostomy was 212 minutes (range 179-322), and the success rate was 100 percent. The authors consider RAL heminephrectomy and ureteroureterostomy to be the procedures of choice over the open procedures.
In contrast to the other procedures, RAL common sheath ureteroneocystostomy had a success rate of 85 percent, which is below the historical gold standard for open procedures. Mean times were 197 minutes (range 188-214) for RAL ureteroneocystostomy without tapering and 279 minutes (range 231-311) with tapering. The authors consider these procedures to be particularly complicated.
“There is a limit to what the robot can do,” explains Dr. Herz. “If the ureter is very dilated for most of its length and you have to extensively taper it, it is best to do that open. In addition, if a case is particularly severe, and you anticipate going into the bladder to fix a ureterocele, you should do that open as well.”
Even clinicians with a great deal of experience in robotic surgery will tend to perform an open surgery if they anticipate an RAL surgery will take too long, says Dr. Herz. The time, the expense of using the robotic system, the experience level of the surgeon and variations in disease process all need to be taken into account before offering RAL surgery for a child with DRA.
“As in anything in medicine and surgery, are the benefits to the child more important than the increased complexity,time and the expense?” says Dr. Herz. “I would say that if you feel confident, you have the experience and you can do the surgery with robot assisted laparoscopy, you should.”
Herz D, Smith J, McLeod D, Schober M, Preece J, Merguerian P. Robot-assisted laparoscopic management of duplex renal anomaly: Comparison of surgical outcomes to traditional pure laparoscopic and open surgery. Journal of Pediatric Urology. 2015 Aug 17. [Epub ahead of print]