1. Paediatric Surgeon & Urologist
Grand Round
17 March 2016
Prakash Mandhan
M.D, Ph.D
Paediatric Surgeon & Urologist

2. Laparoscopic Pyeloplasty
Robotic Assisted
Laparoscopic Pyeloplasty
in Children

3. UPJO and Pyeloplasty
Open Pyeloplasty – standard. Associated with pain, long-stay and scar
Laparoscopic Pyeloplasty – Great alternative option with less pain, short hospital-stay and also minimal scar
Steep learning curve due to difficult intracorporeal suturing in a limited working space

4. Robot-Assisted Surgery
The introduction of robotic surgical system has facilitated precise intracorporeal suturing particularly in small working space and also has greatly reduced the learning curve from simple to complex minimal invasive procedures in children

5. Why Robot-Assisted Surgery
Great - optical magnification
EndoWrist Instrumentation and Improved Dexterity
Three-dimensional operating view
Tremor filtration
Enhanced Ergonomics

6. Robotic Assisted Laparoscopic Pyeloplasty
The first RALP series – 2002*
*M.T. Gettman, R. Neururer, G. Bartsch, R. Peschel. Anderson-Hynes dismembered pyeloplasty performed using the da Vinci robotic system. Urology. 2002;60:
Since then RALP has been adopted by a number of paediatric surgery and paediatric urology centres around the world
Tasian GE, Casale P. The robotic-assisted laparoscopic pyeloplasty: gateway to advanced reconstruction.
Urol Clin North Am Feb;42(1):89-97.

7. Robot-Assisted Surgery
da Vinci Master-slave robotic platform
Surgeon Console
Patient-side Cart
Endowrist Instruments
Vision System

11. Endowrist Instruments

13. Robot-Assisted Surgery in Qatar
Qatar Robotic Surgery Centre
QRSC is a training centre for surgeons and nurses to be involved in robot- assisted surgery at HMC
QRSC is equipped with three da Vinci training robots, a three-dimensional surgical simulator for MIS training and a tele-mentoring theatre for distance training with experts in other countries

14. RALP – Instruments & Supplies
da Vinci Surgical System
8.5mm 0° telescope
12, 8.5 and 5mm ports
Maryland bipolar forceps
Monopolar hood devise or curved scissors
Robotic needle driver
4/0 monofilament absorbable sutures
DJ Stent

15. Redo Pyeloplasty & RALP
Although uncommon, failed pyeloplasty represents a management dilemma and is considered as more challenging because of fibrosis and adhesions in the region of the previously operated UPJ
Transperitoneal RAL approach is well suited for these patients as ideally one will encounter minimal intra-abdominal scarring from the previous retroperitoneal mobilisation
Robot assisted laparoscopic pyeloplasty in patients of ureteropelvic junction obstruction with previously failed open surgical repair. Hemal AK, Mishra S, Mikharjee S et al: Int J Urol 2008; 15: 744.

16. RALP - Worldwide

17. Trainee Interest
The interest in developing RAL surgery is ever increasing
In a recent survey of ACGME accredited paediatric urology fellowship training, robotic/laparoscopic surgery was among the top 3 subspecialty they wanted to be trained*
Role of simulation in robotic surgery for surgeons is growing – various simulators are available for simulation training to assess the skills set in the various tasks
*Pediatric urology fellowship training: are we teaching what they need to learn? Wang MH1, Chen B, Kern D, Gearhart S. J Pediatr Urol Jun;9(3):318-21

18. Take Home Message
RALP is likely to emerge as the new minimally invasive standard of care whenever robotic technology is available because its precise suturing and shorter learning curve represent unique attractive features.
Surgical trainees and young surgeons should be acquitted with this new emerging technology.
The major bottleneck in the development of robot surgery is the capital cost. However like all new technical advancements, this will gradually fall to be within reach of the hospitals.