Impact and Outcomes of a Pediatric Robotic Urology Mini-Fellowship

Introduction: In order to support practicing pediatric surgeons and urologists to safely and effectively incorporate robotic surgery into their practice, we established a 5-day mini-fellowship program with a mentor, preceptor and proctor at our institution. This study was designed to report our experience with the pediatric robotic mini-fellowship (PRM) and to evaluate the impact this course had on the participants' practice.Methods: The mini-fellowship training at our institution is provided in two modules, including upper and lower urinary tract surgery, over a 5-day period. The one to one teacher-to-attendee experience included tutorial sessions, hands-on inanimate, and animate skills training, clinical case observations and video discussions. Participants were asked to complete a detailed questionnaire on their practice patterns before and after the PRM.Results: Between 2012 and 2018, a total of 29 national and international pediatric surgeons and urologists underwent robotic renal and bladder surgery training. Twenty-six fellows (90%) completed the surveys, all of which were included for analysis. The median age at the time of fellowship was 43 years (32–63), and participants had practiced urology for a median of 76 months (3–372). All of them had a laparoscopic background, with a median experience of 120 months (12–372), and an average of 454 (± 703) laparoscopic procedures performed, including the years of training. The most common primary goals of participants were to understand the concept of robotic surgery and its applications (38.5%), and to practice in the wet lab to shorten their learning curve (38.5%). After PRM completion, 24 graduates (92%) felt likely to incorporate robotic surgery into their practice, of which 15 (58%) actually started a robotic program at their home institution. At 24 months after PRM completion, the overall number of surgeries performed with a robotic approach (RA) by these 15 participants was 478 with an average of 32 (± 44) procedures per fellow, of which 109 (23%) were extirpative (nephrectomy, partial nephrectomy, etc.), and 369 (77%) reconstructive procedures (pyeloplasty, ureteral reimplantation, etc.). Before PRM, the same 15 participants performed 844 procedures with a laparoscopic approach (LA), of which 527 (62.4%) were extirpative, and 317 (37.6%) were reconstructive surgeries. These data mark a significant switch in indications for minimally invasive surgery (MIS) in pediatric urology. The rise in the number of reconstructive procedures (37.6% LA vs. 77% RA) has shown that robotic surgery has undoubtedly facilitated the performance of more challenging procedures in a minimally invasive fashion.Conclusion: The success of a mini-fellowship program relies on the commitment of expert faculty to serve as tutorial instructors and proctors. In addition, a completely outfitted robotic laboratory with access to dry and wet lab is indispensable. A 5-day intensive PRM appears to enable postgraduate surgeons to successfully incorporate the robotic platform into their practice and to advance the complexity of minimally invasive procedures, allowing for more challenging surgeries, such as reconstructive urology

Review of robot-assisted laparoscopic surgery in management of infant congenital urology: Advances and limitations in utilization and learning

As robotic-assisted (RAL) surgery expanded to treat pediatric congenital disease, infant anatomy and physiology posed unique challenges that prompted adaptations to the technology and surgical technique, which are compiled and reviewed in this manuscript. From the beginning, collaboration with anesthesia is critical for a safe, efficient case including placement of an endotracheal tube rather than a laryngeal mask (LMA) and placement of a nasogastric tube and/or rectal tube to relieve distended stomach or bowel, respectively. Furthermore, end-tidal CO2 (EtCO2) is important for monitoring and predicting the effects of pneumoperitoneum on caridiovascular physiology, incranial pressure, and risk of acidosis and hypercarbia. Positioning can further exacerbate these effects and affect intra-abdominal working space. For infant robotic pyeloplasty and heminephrectomy, a “beanbag” is commonly used for stabilization in the lateral decubitus position. We advise against the use of a “baby bump” because it brings the bowels and vasculature more anterior than expected. Pnuemoperitoneum pressure of 8–10 mmHg during port placement maximizes safety, but thereafter, the pneumoperitoneum pressure can be minimized to 6–8 mmHg during the procedure without compromising the visual field. Port sites should be marked after insufflation, followed by the open Hasson technique for peritoneal access and port placement under direct vision with intussusception of the trocars to avoid vascular or bowel injury. Additional tips can be obtained through this manuscript, immersive fellowships, and mini-fellowships. Ulitmately, infant robotic surgery has the potential to benefit many children but is presently limited by the lack of pediatric-specific robotic technology and its associated costs

Pediatric robotic urologic surgery-2014

We seek to provide a background of the current state of pediatric urologic surgery including a brief history, procedural outcomes, cost considerations, future directions, and the state of robotic surgery in India. Pediatric robotic urology has been shown to be safe and effective in cases ranging from pyeloplasty to bladder augmentation with continent urinary diversion. Complication rates are in line with other methods of performing the same procedures. The cost of robotic surgery continues to decrease, but setting up pediatric robotic urology programs can be costly in terms of both monetary investment and the training of robotic surgeons. The future directions of robot surgery include instrument and system refinements, augmented reality and haptics, and telesurgery. Given the large number of children in India, there is huge potential for growth of pediatric robotic urology in India. Pediatric robotic urologic surgery has been established as safe and effective, and it will be an important tool in the future of pediatric urologic surgery worldwide

The LUAA Gundeti Technique for Bilateral Robotic Ureteral Reimplantation: Lessons Learned over a Decade for Optimal (Resolution, Urinary Retention, and Perioperative Complications) Trifecta Outcomes

Background: Ureteral reimplantation is the gold standard treatment for high-grade vesicoureteral reflux (VUR) in pediatric patients. Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) using the LUAA technique has emerged as a viable alternative to traditional open and laparoscopic surgical correction. Objective: To evaluate the outcomes, reflux resolution, urinary retention, and complications associated with bilateral RALUR-EV for primary VUR using the LUAA Gundeti technique in pediatric patients. Design, setting, and participants: A retrospective study was conducted at a single academic center, involving 34 consecutive pediatric patients who underwent RALUR-EV for bilateral VUR management between December 2008 and December 2022. The study included only patients who were evaluated with postoperative voiding cystourethrogram (VCUG). Surgical procedure: The LUAA extravesical ureteral reimplantation technique was performed, involving the identification and mobilization of the ureter, creation of a peritoneal window, dissection close to the neurovascular bundle, Y dissection at the ureterovesical junction, detrusorotomy, detrusorrhaphy with advential inclusion, and apical alignment suture. Measurements: The primary outcome was radiographic resolution of VUR on VCUG. The secondary outcomes included urinary retention and Clavien-Dindo grade III complications. Results and limitations: The overall radiographic resolution rate was 85.2%, with success rates of 76.7%, 75%, and 96.7% across the three distinct patient cohorts. The overall Clavien-Dindo grade III complication rate was 5.8%, and transient urinary retention was 8.8%. Resolution of urinary retention occurred within 7–28 d. The study's limitations include the small sample size, single-center design, and retrospective nature. Conclusions: The LUAA technique demonstrates sustainable outcomes for VUR resolution with a low incidence of transient urinary retention and complications. A thorough understanding of pelvic anatomy is essential for successful dissection and minimization of the risk of complications. Further studies are needed to evaluate the effectiveness of different approaches in reducing the incidence of transient urinary retention following bilateral extravesical reimplantation. Patient summary: In this study, we examined the results of the Gundeti LUAA surgical technique for treating primary vesicoureteral reflux in children. We identified various essential modifications that increase the likelihood of achieving favorable outcomes

A 10-step procedure for distal hypospadias repair with 50% resident involvement is safe and effective

Background: Pediatric urological surgeons have long recognized hypospadias repair to be technically challenging. Resident involvement during hypospadias repair is reportedly limited due to this perceived difficulty. Objective: To 1) describe a consistent 10-step streamlined surgical technique where senior urology residents perform half of a distal hypospadias repair 2) report outcomes of these procedures 3) review current literature regarding resident involvement in hypospadias repair. Subjects and methods: A retrospective analysis was performed for 147 patients who underwent distal hypospadias repair between July 2008 and July 2019 at an academic tertiary center children's hospital. Hypospadias repairs were included for one-stage procedures with a mid-penile or distal meatal location. A systematic literature review was conducted to search for articles regarding resident experiences in hypospadias repair and used for comparing outcomes. Surgical procedure and measurements: The surgery was performed with a variation of the TIP technique, which was divided into 10-steps with equal resident and attending participation. Complications were significant if they required additional surgical intervention. Results: Average patient age was 19.5 months with an average follow-up of 18.4 months. Overall, nine patients (6.1%) developed complications that required surgical reintervention. Urethrocutaneous fistula occurred in 5 (3.4%). Meatal stenosis developed in 3 (2.0%). One patient developed a skin tag (0.7%). These were comparable to rates found in the literature review. Suggested methods for improving surgical training and repair outcomes, per the literature review, include attendings reviewing their own outcomes, determining key consistent streamlined surgical steps to teach, concentrated experience of caseloads for residents, and strict guided supervision through the entire procedure. Conclusion: Our results with streamlined and consistent surgical steps and 50% resident involvement demonstrate that it is feasible to incorporate residents into this highly-technical procedure, which helps to build the foundation of microsurgical skills for urology residents without compromising the outcomes or duration of surgery in this special population