Initial Experience of Single-port Robotic assisted Laparoscopic Ureteroureterostomy In Infant Duplex Systems with Upper Urinary Tract

doi:10.21203/rs.3.rs-4873458/v1

Purpose Robotic assisted laparoscopic single port surgery (R-LSPS) has attracted more and more attention as its safety and stably function, and the patients demand for less scars after surgery. Due to the limitation of operating space in infant, there is no report about R-LSPS ureteroureterostomy before. We present the experience of R-LSPS ureteroureterostomy by Da Vinci Xi in 5 infant.

Methods The clinical data of 5 infants of duplex kidney with upper urinary tract treated by R-LSPS ureteroureterostomy were collected from December 2021 to December 2023. All cases were female, aged 0.8-3.2 months (mean age 1.6± 1.0 months). The body measurements, operation time, bleeding loss, complications, length of hospitalization and other indexes were recorded. Doppler ultrasound, urine routine and urine culture were regularly rechecked after operation. The follow-up time was 6-29 months.

Results The operation were done with the DaVinci Xi system. We made a 2.5-3cm incision at the lower edge of the umbilicus, inserted the a Gelport™ device without use of additional ports. Median operation time was 124.4±21.8min, median hospital stay time was 7.6±2.7 days (D), median bleeding volume was 9.0±4.2 ml. One infant had urine leak, with the sufficient drainage, the drainage tube was removed on the 8th day after surgery, on postoperative follow-up there was no ureteral stenosis. There were no complications observed on follow-up. Wounds recovered well at follow-up.

Conclusion R-LSPS ureteroureterostomy is safe and feasible in infant duplex systems with upper urinary tract.

Single port

Upper Urinary Tract

Robotic-assisted surgery

Infant

Ureteroureterostomy

The Duplex systems is one of the common diseases in pediatric urology with an incidence rate of about 8/1000. The symptom of this disease is insidious and asymptomatic.^[1–2]. Complete upper urinary tract abnormality is one of the types, it can lead to urinary tract infection, incontinence, obstruction or abnormal urination accompanied by hydronephrosis^[3–4].

Ureteroureterostomy is an effective way for the upper urinary tract in a duplicated system, Recently, minimally invasive surgery develop rapidly, robotic assisted laparoscopic ureteroureterostomy has been reported in some institutions^[5–7]. Villanueva CA^[5] compared 12 open and 8 robotic infants ureteroureterostomy, concluded that, robotic assisted laparoscopic ureteroureterostomy is safe and effective in infant, compared to traditional surgery, it was similar in surgical time and complications rata.

Moreover, robotic assisted laparoscopic single port surgery (R- LSPS) has attracted more and more attention as its safety and stably function, and the patients demand for less scars after surgery. Now R- LSPS has been widely used in adult urology and gynecology ^[8–10]. In pediatric surgery, Rosales-Velderrain et al. first reported the application of R- LSPS in pediatric cholecystectomy in 2017 ^[11]. However, as far as we are aware there is no report about the application of R- LSPS in infant duplex systems due to the limitation of operating space. The present study share the experience of 5 infant who had duplex kidney with upper urinary tract and treated by Da Vinci Xi single port laparoscopic surgery from December 2021 to December 2023.

1. Clinical data

This is a retrospective study of infant underwent single-port robotic assisted laparoscopic ureteroureterostomy, all 5 cases were female, 0.8–3.2 months (mean age 1.6 ± 1.0 months),with upper urinary tract. Prenatal diagnosis of duplicated system, and postnatal UTI, recurrent pyelonephritis and recurrent fever. Two infants under 1 month with ureteral cysts were performed transurethral incision of the ureterocele at the age of born 2 weeks, but still have UTI under antibiotic intervention 2 weeks after operation.

Pre-operation, MRU, VCUG, Doppler ultrasound were performed, no lower pole vesicoureteral reflux(VUR) found. Except 2 infant under 1 month, the other 3 patients were performed dimercapto-succinic acid renogram(DMSA) ,the upper pole renal all functioning.

This study was approved by the Medical Ethics Committee of Wuhan University Zhongnan Hospital (2,022,003 K).

2.Surgical operations

Cystoscopy was performed first, 3Fr double J stent was placed on the lower pole ureteral. Then we placed the patients in a 45-degree lateral decubitus position.

All cases were done with the DaVinci Xi system. We made a 2.5-3cm incision at the lower edge of the umbilicus, then entered the peritoneal cavity, and inserted a Gelport™ device without use of additional ports. 4 working ports with 10mm trocars are placed via the Gelport. Robot arm 1 and arm 3 are used as working arms and placed into the working port. Arm 2 is connected to the endoscope and placed into the endoscope port. The endoscope port and the two working ports are arranged in an equilateral triangle(Fig. 1).

Uretero-ureterostomy

Guided by the double J stent, we have avoided accidental injury to the lower pole ureter, we use blunt dissection and electrocautery to separate the upper pole ureter. The distal end was cut by monopolar scissors, then ligated near the bladder neck or vagina. An extracorporeal hitch stitch to distracting the uterus gently to improve exposure, then we cut off the upper pole ureter near the iliac vessels level, and make a longitudinal incision on the inner side of the lower pole ureter at the same place, and intermittently suture with 6 − 0 poly-propylene suture to anastomose the two ureters end-to-side(Fig. 2). Drainage tube were placed in the pelvic cavity through the umbilicus.

3.Intraoperative and postoperative conditions

The indicator of removing the drainage tube is that the drainage volume is less than 20mL for two consecutive days. Double J stent was removed 4–6 weeks after surgery. Doppler ultrasound, urine routine and urine culture were regularly rechecked in the outpatient department after surgery. The follow-up time was 6–29 months. We recorded the body measurements, operation time, bleeding loss, complications, length of hospitalization, etc.

Between December 2021 to December 2023, 5 infants R-LSPS ureteroureterostomy were completed. Median operation time was 124.4 ± 21.8min, median hospital stay time was 7.6 ± 2.7 days (D), median bleeding volume was 9.0 ± 4.2 ml. (Table.1)

One infant had urine leak. As the drainage tube were placed in the pelvic cavity, urine leak sufficient drainage out. Human serum albumin is used to eliminate edema, cefotiam is used to anti-infections. The patient did not experience vomiting or abdominal pain. The drainage tube was removed on the 8th day after surgery, on postoperative follow-up there was no ureteral stenosis after Double J stent removed; 1 case had UTI and needed intravenous antibiotic therapy after surgery.

At a mean follow up of 15.6 months (range 6–29) all patients were clinically well, and had no UIT, no significant hydronephrosis, and the ureter was not dilated. Wounds recovered well at follow-up (Fig. 3).

Since the first report of the application of R- LSPS in adult surgery in 2009 ^[12], it has been widely used in adult urology, general surgery, gynecology, etc. Both laparoscopic single port surgery (LSPS) and Da Vinci robotic surgical system are international cutting-edge minimally invasive technologies, and the combination of the two -the R-LSPS -is a major technological breakthrough in the field of minimally invasive surgery.

Laparoscopic UU has been reported as a safe treatment for patients with duplex kidney^[13–14].But this technical difficulties with delicate operations and suturing^[15], while the Da Vinci surgical system has the advantages: 3D vision with 15 times magnification, 360 degrees rotated lens, flexible robotic arms, tremor filtration, all of these strengths make the operation precisely and delicately. Surgeons can adjust the endoscope by themself according to the intraoperative situation, reduce the interference from improper cooperation; the wrist can be rotated freely, which enables the operator to complete the operation in the place that cannot be reached by human hands ^[16]. Robotic assisted laparoscopic surgery is much closer to open surgery than laparoscopic surgery ^[17], it is more suitable for precise suturing.

Kutikov^[18] first reported RAL-UU in pediatric patient in 2007, then RAL-UU has been evolved, some institutions reported RAL-UU in infant^[19–21]. We have reported Single-port robot-assisted laparoscopic pyeloplasty in an 9 month infant^[22], proved the safety and efficacy of this technology. In this study, we used Da Vinci Xi robotic surgical system to complete single-port RAL-UU in infant duplex kidney with ectopic ureter. The single port was inserted via umbilicus, with the endoscope port located in the middle and the two robotic manipulation ports located on both sides, the endoscope port and the two working ports are arranged in an equilateral triangle. During the operation, two robotic manipulation may located on the same side of the endoscope port, due to the three trocars are fixed through a single port device and cannot penetrate the belly like the trocars of multi-port robot. Assistants should pay attention to adjusting the position of the three trocars keep the equilateral triangle, thus ensure us reduce instrumental crowding and clashing.

In our study, 5 cases of R- LSPS UU were successfully completed without open conversion or use of additional ports. The average operation time was 124.4 ± 21.8min, median hospital stay time was, median bleeding volume was 9.0 ± 4.2 ml. The average length of postoperative hospital stay was 7.6 ± 2.7 days (D), which is associated with the lack of primary medical resources in our country. Our outcomes are comparable to open and laparoscopic UU ^[23–24].

To solve the problem of infants smaller operating space, all 5 babies undergo water enema 12 hours pre-operation, prevents the intestinal canal from expanding, and makes it easier to reveal the spatial view and also reduce the risk of intraoperative accidental injury to the intestinal canal. During the operation we placed the patients in a 45-degree inclined position at the waist of the affected side, under the influence of gravity, the renal area is located at its highest point, exposing the surgical area maximum. Da Vinci Xi trocar avoids deep insertion into the abdominal cavity, thereby increasing surgical space and reduce of instruments collision. We use 5 − 0 poly-propylene suture to suspension of peritoneum with thin wires to expose the surgical area, facilitate operator’s intraoperative manipulation.

One infant had urine leak. This complication is rarely described in the literature. Due to the poor surgical area exposure, lead to excessive suture spacing during the anastomosis of the posterior wall of the ureter. In the subsequent surgery, we use of“hitch-stitch”technology^[25] to ensure the surgical area exposure. Furthermore, the upper pole ureter should be adequate dissection, which can minimize tension, realize tension-free anastomosis. As the drainage tube were placed in the pelvic cavity, urine leak sufficient drainage out. Human serum albumin is used to eliminate edema, cefotiam is used to anti-infections. The patient did not experience vomiting or abdominal pain. The drainage tube was removed on the 8th day after surgery, on postoperative follow-up there was no ureteral stenosis after Double J stent removed.

It should be noted that parents and surgeons have been concerned about the aesthetics of the postoperative wound in the treatment. Barbosa et al. ^[26] thought that some parents choose the robotic surgery because robotic postoperative scars are more aesthetically pleasing than open scars. Gargollo et al. ^[27] placed two port positions horizontally in the Pfannenstiel incision and a third port position in the umbilicus to conceal the surgical wound from the Pfannenstiel line and the navel. In this study, a 2.5 cm long curved incision was made through the lower edge of the umbilical ring, and a single port device was inserted through the umbilicus. The surgical scar was concealed in the navel to maximize the postoperative aesthetic effect.

The R-LSPS UU in infant is safe and feasible. The surgical wound is hidden in the navel to realize the less scar effect. The deficiency of this study is that the sample size is small, and the follow-up time is short, which still needs to be verified by a randomized controlled study with large sample size.

R-LSPS Robotic assisted laparoscopic single port surgery

UTI Urinary Tract Infection

MRU Magnetic resonance urography

CTU Computed tomography urography

VCUG Voiding cystourethrography

RAL Robotic assisted laparoscopic surgery

UU Ureteroureterostomy

Ethics approval and consent to participate

The protocol for this research project has been approved by a suitably constituted Ethics Committee of the institution and it conforms to the provisions of the Declaration of Helsinki. Written informed consent was obtained from the parents or legal guardians of any participant under the age of 16.Ethical Approval for Clinical/Scientific Research Projects under Medical Ethics Committee, Zhongnan Hospital of Wuhan University. Committee ID:2022003K.

Consent for publication
Not applicable.

Competing Interests

The authors have no conflicts of interest to declare.

Funding

This study was supported by funds from Zhongnan Hospital of Wuhan University Discipline Capacity Building Project (YYXKNLJS2024020).

Author Contribution

Wen Zhang and Heyun Gao contributed to the conception and design; Yunkai Guo contributed to the drafting of the manuscript; Kun Yang , Mingshuang Luo, Zhenfang Qin and Shanzhen Yu contributed to the acquisition, analysis, and interpretation of data; Geng Li, Tao Hu, Guowei Du, Yifan Liu contributed to the administrative technical or material support.

Acknowledgements

Not applicable.

Data Availability

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.

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Table 1. Patient Demographics

Patient		BMI	Age (months)	Location of hydronephrosis	Presentation		Operative time (min)		Bleed loss (mL)	LOS(days)		Complications
	1	13.2	0.8	Right upper		febrile UTI		125	15		12	none
	2	13.2	1.1	Left upper		incontinence, febrile UTI		132	5		8	urine leak
	3	15.9	2.2	Left upper		febrile UTI		150	10		5	UTI
	4	19.8	3.2	Right upper		febrile UTI		125	10		6	none
	5	17.2	0.9	Right upper		febrile UTI		90	5		7	none

No competing interests reported.

Initial Experience of Single-port Robotic assisted Laparoscopic Ureteroureterostomy In Infant Duplex Systems with Upper Urinary Tract

Status:

Version 1

Abstract

Figures

Introduction

Methods

1. Clinical data

2.Surgical operations

Uretero-ureterostomy

3.Intraoperative and postoperative conditions

Results

Discussion

Conclusions

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication
Not applicable.

Competing Interests

Funding

Author Contribution

Acknowledgements

Data Availability

References

Tables

Additional Declarations

Status:

Version 1

Initial Experience of Single-port Robotic assisted Laparoscopic Ureteroureterostomy In Infant Duplex Systems with Upper Urinary Tract

Status:

Version 1

Abstract

Figures

Introduction

Methods

1. Clinical data

2.Surgical operations

Uretero-ureterostomy

3.Intraoperative and postoperative conditions

Results

Discussion

Conclusions

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication Not applicable.

Competing Interests

Funding

Author Contribution

Acknowledgements

Data Availability

References

Tables

Additional Declarations

Status:

Version 1

Consent for publication
Not applicable.