1. Robotic Pyeloplasty vs Laparoscopic Pyeloplasty
Dr. Altaf Khan, Dr. Mujeeburahiman, Dr. Nischith D’souza, Dr. Ashish Verma, Dr. Rahul Bhargava Department of Urology, Yenepoya Medical College Hospital, Deralakatte, Mangalore, Karnataka
Abstract
Results
A total number of 25 cases of pyeloplasties were performed in our institution between July 2015 to July Out of which 8 were robotic and 17 were laparoscopic.
Patients age, sex, BMI were all comparable in both the groups. Mean operative time was 85  minutes for laparoscopic and 115 min for robotic. If the docking time was excused, then the mean operating time for robotic pyeloplasty was 71 min. The suturing time for laparoscopic arm was 45 minutes where as suturing time for robotic arm was 20 min.
Patients who underwent robotic pyeloplasty experienced and significantly lower post-operative pain as compared to those who underwent laparoscopic pleloplasty.
The mean hospital stay for robotic and laparoscopic patients was comparable (2.1 and 2.4 days, respectively), and was the outcome of the procedure at six months with none of the cases showing an obstructive pattern on renogram scan.
Laparoscopic pyeloplasty is the gold standard for treatment of Uretero Pelvic Junction obstruction. With installation of Robot in every nook and corner Robotic Pyeloplasty is gaining acceptance. Is it worth it?
Materials and Methods: A total number of 25 cases of pyeloplasties were performed in our institution between July 2015 to July Out of which 8 were robotic and 17 were laparoscopic.
Results: Mean operative time was 85  minutes for laparoscopic and 115 min for robotic. If the docking time was excused, then the mean operating time for robotic pyeloplasty was 71 min. The suturing time for laparoscopic arm was 45 minutes where as suturing time for robotic arm was 20 min.
Conclusion: The development of Robotic assisted laparoscopic pyeloplasty has reduced the obstacles to learning intracorporeal suturing, which is the main reconstructive step in pyeloplasty. If we are able to utilise the resources with great shrewdness then robotic pyeloplasty is definitely a better option for UPJ obstruction. 
Discussion
Laparoscopy is one of the most significant advances of the twenty-first century surgical armamentarium, allowing significantly better cosmesis, lower pain, blood loss, and convalescence, with no loss of functional or oncological outcomes. One of the major issues with laparoscopy was the steep learning curve, partly due to the two-dimensional vision and limited movement of instruments. This was particularly evident in reconstructive procedures, which, in urology, consisted mainly of vesicourethral anastomosis and pyeloplasty. This led to these procedures being classified as ‘advanced’ and were performed by relatively few very skilled surgeons.[6]
The da Vinci robot is clearly a marvel of technology; it helped overcome these limitations and has the potential to change the practice of urologic surgery. Three-dimensional vision, sophisticated wristed instruments, dampening of tremor, and excellent ergonomics all favor its application to a variety of urologic laparoscopic procedures. However, disadvantages such as high cost, loss of tactile feedback, and consumption of operating room resources counsel a reasoned assessment of da Vinci's application. Several groups have reported the use of the da Vinci system for performing RLP with favorable results.6–8 In this study, we performed a direct comparison of primary laparoscopic dismembered pyeloplasty performed with and without the da Vinci by a single surgeon experienced with both the robotic and traditional laparoscopic techniques. As many variables as possible, such as the experience of the operating room staff, were kept constant to provide a valid comparison. Despite the theoretical suturing advantages of the da Vinci, the robotic pyeloplasty cases had significantly longer mean operative (by 30 minutes) but if we exclude the docking time then they finished 14 mins earler than the laparoscopic pyeloplasty cases. In contrast, anesthesia setup and wake times, ureteral stenting and positioning times, age, and body mass index were not significantly different between the two techniques.
Gettman et al14 retrospectively compared their initial 6 patients after RP with 6 age-matched LP controls and concluded that operative times were improved with robotic assistance (140 min vs 235 min) as was suturing time (70 min vs 120 min). Hospital stay (4 days), estimated blood loss (<50 mL), and complications (none) were equivalent between the 2 groups. In another review15 with 9 patients, in which a 4-port RP technique was used, operative time was 139 minutes, suturing time was 62 minutes, hospitalization was 5 days, and blood loss was minimal.
In our study, the operating times were longer. The times reported included the time for setting up the robotic system. Furthermore, our overall experience with the robotic system had been minimal, before this series of patients. We have noted a significant decrease in our robot setup time since this series of patients underwent surgery. A significant, unmeasured, parameter noted in our series was of surgeon fatigue. Despite only marginally higher operative times, fatigue at the end of a well-performed conventional laparoscopic pyeloplasty discouraged the performance of a second procedure the same day. Increasing fatigue results in increased tremor and placing precise sutures can be difficult when the surgeon is tired. This became evident to us when we realized that we were routinely performing more than one reconstructive procedure, pyeloplasty or radical prostatectomy, when robotic assistance was available, while on no day were two laparoscopic procedures performed. Although it has been previously documented that laparoscopy is associated with increased risk of injuries to the surgeon, a comparison of the ergonomic outcomes between robotics and laparoscopy for the surgeon would be worth performing.
Introduction
Over the last century, the surgical management of ureteropelvic junction obstruction (UPJO) has dramatically evolved.1 Various open surgical techniques have been described based on the cause, location, and length of the UPJO. The most popular repair is the Anderson-Hynes dismembered pyeloplasty, which has universal application and is accepted as the gold standard of treatment.2–5
With the development of endoscopic techniques and equipment, minimally invasive approaches have come into favor in the treatment of patients with primary and secondary UPJO. A variety of endoscopic treatments via antegrade and retrograde approaches have been described.6–12 More recently, with advancing laparoscopic skills and the introduction of robotic-assisted surgery, many centers have moved to laparoscopic pyeloplasty (LP) as first-line therapy.13–27 Improved suturing skills and the use of robotic assistance have greatly facilitated laparoscopic dismembered pyeloplasty for primary and secondary repairs.
This study was undertaken to compare the results of laparoscopic and robotic pyeloplasty.
Materials and Methods
A total number of 25 cases of pyeloplasties were performed in our institution between July 2015 to July Out of which 8 were robotic and 17 were laparoscopic.
For robotic pyeloplasty, three arms of the four-arm da Vinci S surgical system were used with one additional 10 mm port for the assistant. For laparoscopic pyeloplasty, a three port technique was used in all cases. An additional 5mm port was used for liver retraction in right-sided procedures. All anastomoses in both sets of cases were performed with 4-0 polyglactin sutures. An antegrade ureteric stent was also placed in all patients. A peri-renal drain placed at the end of the procedure was removed when the 24-hour output was less than 50 mL. Urethral catheters were removed the following day. A diuretic renogram was obtained between three and six months after stent removal. Success was defined as the resolution of symptoms with non-obstructive outflow on the renogram. All patients provided informed consent for the surgeries.
Parameters that were compared were the operating time, docking time, the suturing time, hospital stay, post-op pain and the outcome after six months.
Conclusion
Duration of surgery
Dissection time
Suturing time
Post op pain
3D Lap
85 min
25 min
45 min
+++
ROBOTIC
71 min
15 min
20 min +
The development of Robotic assisted laparoscopic pyeloplasty has reduced the obstacles to learning intracorporeal suturing, which is the main reconstructive step in pyeloplasty. If we are able to utilise the resources with great shrewdness then robotic pyeloplasty is definitely a better option for UPJ obstruction.
Refrences
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