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| The robot-assisted ureteral reconstruction in adult: A narrative review on the surgical techniques and contemporary outcomes |
Kulthe Ramesh Seetharam Bhata,*( ),Marcio Covas Moschovasa,Vipul R. Patela,Young Hwii Kob
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a Department of Urology, AdventHealth Global Robotics Institute, Celebration, FL, United States
b Department of Urology, Yeungnam University, Daegu, Republic of Korea |
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Abstract Despite the rapid increase in the use of robotic surgery in urology, the majority of ureteric reconstruction procedures are still performed using laparoscopic or open approaches. This is primarily due to uncertainty regarding the advantages of robotic approaches over conventional ones, and the unique difficulty in identifying the specific area of interest due to the lack of tactile feedback from the current robotic systems. However, with the potential benefits of minimal invasiveness, several pioneering reports have been published on robotic surgery in urology. By reviewing the literature on this topic, we aimed to summarize the techniques, considerations, and consistent findings regarding robotic ureteral reconstruction in adults. Robotic applications for ureteral surgery have been primarily reported for pediatric urology, especially in the context of relieving a congenital obstruction in the ureteral pelvic junction. However, contemporary studies have also consistently demonstrated that robotic surgery could be a reliable option for malignant, iatrogenic, and traumatic conditions, which generally occur in adult patients. Nevertheless, the lack of comparative studies on heterogeneous hosts and disease conditions make it difficult to determine the benefit of the robotic approach over the conventional approach in the general population; thus, qualified prospective trials are needed for wider acceptance. However, contemporary reports have demonstrated that the robotic approach could be an alternative option for ureteral construction, even in the absence of haptic feedback, which can be compensated by various surgical techniques and enhanced three-dimensional visualization.
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Received: 22 December 2019
Available online: 20 January 2021
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Corresponding Authors:
Kulthe Ramesh Seetharam Bhat
E-mail: Seetharam_bhat2003@yahoo.co.in
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| Study | Number of patients | Operative time, min | Length of stay, day | Complication | Success rate (%) | Comment | | Patel, 2005 [58] | 50 | 122 | 1.1 | None | 96 (48/50) | Stent-20 days | | Schwentner et al., 2007 [59] | 92 | 108 | 4.6 | 3 needed re-intervention for stricture | 97 (89/92) | Stent-6 weeks | | Gupta et al., 2010 [14] | 85 | 121 | 2.5 | 8 | 97 (82/85) | Stent in all | | Erdelijan et al., 2010 [60] | 88 | 168 | 2.5 | 5 major, 3 minor | 95 (84/88) | Stent in all | | Hemal et al., 2010 [61] | 60 (30-Robotic) | 145 | 2.0 vs. 3.5 (RP vs. LP) | 1 stricture in laparoscopic | 100 vs. 97 (LP vs. RP) | Stent in all | | Bird et al., 2011 [62] | 172 (98-Robotic) | 189 | 2.5 in all groups | 1% | 93 | Stent in all (large dilated pelvis is not included) | | Pawha et al., 2014 [63] | 90 (30-Robotic) | 142 | 2.5 (RP) | 8 in Robotic group | 96 | Surgeon fatigue was less compared to other modalities. | | Danuser et al., 2014 [64] | 114 (81-Robotic)
(Two groups; I-1 week stenting vs. II-4 week stenting) | 200 (Group I) vs. 192 (Group II) | 5 vs. 6 | Group I-2/50 (Minor) vs. Group II-3/50 (2-Major, 1- Minor) | 98-100 | Stent 1 week (50%)
Stent 4 week (50%)
Groups with 1 week and 4 week stenting have same outcome. |
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Summary of articles on robotic pyeloplasty in adults (n > 50).
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| Study | No. of patient | Pediatric/adult | Benign/malignant disease | Diagnosis | Operation | Total operative time (robotic time, min) | Complication | Follow-up (month) | Recurrence (in case of malignant disease) | | Yohannes et al., 2003 [33] | 1 | Adult | Benign | Stricture and endoscopic failure | Distal ureterectomy and reimplantation | 210 | None | 5 | None | | Mufarrij et al., 2008 [53] | 4 | Adult | Benign | 3-Iatrogenic injury
1-Congenical | Distal ureterectomy and reimplantation | 239 | None | 31.5 | None | | Uberoi et al., 2007 [65] | 1 | Adult | Malignant | UTUC | Distal ureterectomy and reimplantation with a psoas hitch (endoscopic incision on ureteral orifice) | NA | NA | NA | NA | | Williams and Leveillee, 2009 [66] | 7 | Adult | Benign | 3-Stone
2-Iatrogenic injury
1-Ureterovaginal fistular
1-Endometriosis | Distal ureterectomy and reimplantation | 247 | 1-Anastomic stricture | 18 | 1-anastomic stricture | | Schimpf and Wagner 2009 [43] | 11 | Adult | Malignant
Benign | 6-UTUC
5-Benign stricture | Distal ureterectomy and reimplantation | 189.3 (average) | 2-Flank pain without radiologic evidence | 20.5 (average) | NA | | Glinianski et al., 2009 [36] | 9 | Adult | Malignant | UTUC (5-below pT1) | Distal ureterectomy and reimplantation | 252 | 1-Ureteral stricture
1-Aspiration pneumonia | 23 | 5-intravesical recurrence
1-ipsilateral renal pelvis | | Eandi et al., 2010 [34] | 4 | Adult | Malignant | UTUC (3-below pT1; 1-pT2) | Distal ureterectomy and reimplantation | 311 | 1-Urine leak with ileus | 30.5 | 1-systemic recurrence | | Kozinn et al., 2012 [39] a | 10 | Adult | Benign | 5-Iatrogenic injury
5-Stone | Distal ureterectomy and reimplantation (4-Psoas hitch) | 306.6 | None | 24 | None | | Baldie et al., 2012 [67] | 13 (among 16 robotic series) | Adult | Benign | 7-Stone
6-Iatrogenic injury | Distal ureterectomy and reimplantation (8-Psoas hitch) | 266.7 | 2-Open conversion
1-Boewl injury | 6.4 | None | | McClain et al., 2012 [37] | 4 (among 6 robotic series) | Adult | Malignant | 3-UTUC (1-CIS, 1-pT1, and 1-pT2) 1-B cell lymphoma | Distal ureterectomy and reimplantation (3-Psoas hitch) | 279 (average) | None | 32.7 (average) | 1-intravesical recurrence | | Lee et al., 2017 [32] | 10 | Adult | 8-Benign
2-Malignant | 1-UTUC
1-Endometrial stromal sarcoma | Distal ureterectomy and reimplantation (5-Psoas hitch) | 211 | 2-Clavien Ⅱ (1-Hypoxia;
1-Hemorrage) | 28.5 | 2-stricture recurrence | | Isac et al., 2013 [40] a | 25-Robot
41-Open | Adult | Benign | Robot-20 stricture (5 iatrogenic)
Open-32 stricture (9 iatrogenic) | Distal ureterectomy and reimplantation (4-Psoas hitch and
10-Boari flap) | 297-Robot
200-Open | Robot (2-Clavien III)
Open (1-Clavien II; 2-Clavien III; 1-Clavien Ⅳ) | 11.6-Robot
44.5-Open | Reoperation
2 (7.6%)-Robot
4 (9.7%)-Open | | Elsamra et al., 2014 [41] b | 20-Robotic 85-Laparoscope
25-Open | Adult | Benign
Malignant | Malignant
6-Robotic 14-Laparoscopic
9-Open
Rest of the cases were benign. | Distal ureterectomy and reimplantation (6/1/12-Psoas hitch and 8/44/8-Boari flap) | 236-Robot
235-Laparoscopic257-Open | Clavien III(2-Robotic;10-Laparoscopic;5-Open) | In weeks (16-Robotic; 79-Laparoscopic; 58-Open) | 2 (10%)-Robot
5 (5.9%)-Laparoscopic
5 (20%)-Open | | Fifer et al., 2014 [35] | 55 | Adult | Benign
Malignant | 45-Benign
10-Malignant | 35-Ureteroneocystos-tomy without psoas hitch
10-Distal ureterectomy
9-Boari flap
5-Ureterolysis
5-Ureteroureterostomy
2-Ureterolithotomy
1-Reimplant to neobladder | 233 | 2 over Clavien Ⅲ (1-acute oxygen desaturation;
1-rebleeding) | 6 | 3c | | Pugh et al., 2015 [68] | 8 | Adult | 4-Benign
4-Maligant | 2-Below pT1
2-Beoynd pT2 | Distal ureterectomy and reimplantation | 285 | 1-Readmission for dehydration (Ⅰ); | NA | NA | | Kaouk et al., 2019 [8] | 3 | Adult | 3-Benign | DaVInci SP system (2-extra port and 1-no extra port) | Distal ureterectomy and reimplantation (1-bilateral reimplantation) | 165 | 1-Nausea (Ⅰ) | NA | NA |
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Summary of articles on distal ureterectomy with reimplantation during robot-assisted ureteral reconstruction.
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| Study | No. of patients | Benign/malignant disease | Diagnosis | Operation | Total operative time (robotic time, min) | Complication | Follow-up (month) | Recurrence | | Schimpf and Wagner 2008 [69] | 1 | Benign | Ureteral stricture | Distal ureterectomy and reimplantation with Boari flap | 150 (Robotic) | Mild hydronephrosis | 6 | None | | Schimpf and Wagner 2009 [43] | 2 (Among 11 cases of distal ureterectomy) | 1-Benign
1-malignant | 1-Benign
1-UTUC (Ta high grade) | Distal ureterectomy and implantation with Boari flap | 169 (Robotic) | 1-External iliac vein injury repaired robotically
1-Ileus | 1-12
1-4 | None | | Allaparthi et al., 2010 [70] | 2 | Malignant | 2-UTUC (below pT1) | Distal ureterectomy and implantation with Boari flap | 245 | None | 6 | None | | Yang et al., 2011 [71] | 2 (Among 3 cases) | 1-Benign
1-Malignant | 1-Iatrogenic
1-pTa UTUC | Distal ureterectomy and implantation with Boari flap (1-with Psoas hitch) | NA | 1-Arterial flutter | NA | None | | Musch et al., 2012 [72] | 1 (Among 9 cases of distal ureterectomy) | Malignant | UTUC | Segmental ureteral resection with lymphadenectomy and Boari flap | 320 | None | 12 | None | | Musch et al., 2013 [42] | 5 (Among 16 ureteral reimplantation) | 2-Benign
3-Malignant | 2-UTUC
1-Prostate Ca | Distal ureterectomy with reimplantation with Boari flap | 287 (In average) | 1-Recurrent tumor on bladder and ureter and renal pelvis
1-Hydronephrosis due to anastomotic stricture | 11.3 (in average) | 1-Additional endoscopic treatment | | Do et al., 2014 [44] | 8 | 5-Benign
3-Malignant | 3-Iatrogenic
1-Trauma
1-Stricture
3-UTUC | Distal ureterectomy with reimplantation with Boari flap | 171.9 | 1-Prolonged anastomotic leak | 12 | None | | Slater et al., 2015 [6] | 3 (Among 14 distal ureterectomy) | 3-Benign | | Distal ureterectomy with reimplantation with Boari flap | 315 (In average) | 1-Fever | 20.6 (in average) | None | | Stolzenburg et al., 2015 [73] | 11 | Benign | | Distal ureterectomy with reimplantation with Boari flap | 166.8 | 1-Prolonged catheterization due to anastomotic leak | 12.5 | None |
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Summary of articles on Boari flap during robot-assisted ureteral reconstruction.
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| Study | No. of patients | Paediatric/adult | Benign/malignant disease | Diagnosis | Total operative time (robotic time, min) | Complication | Follow-up (month) | Recurrence (in case of malignant disease) | | Mufarriji and Stifelman 2006 [51] | 2 (Among 63 cases) | Adult | Benign | Stricture | 218.5 | None | 12.5 | None | | McClainet al. 2012 [37] | 2 (Among 6 cases with UTUC) | Adult | Malignant | UTUC (2-pTa) | 237.5 (in average) | None | 33.5 (in average) | None | | Baldie et al., 2012 [67] | 3 | Adult | Benign | 3-Stone | 223 | None | 6.4 | None | | Lee et al., 2015 [5] | 25 | Pediatric | Benign | 3-Ureterocele
18-Ectopic ureter
4-Stricture | 186 (158) | 4-Urinary tract infection (Clavien 2) | 16.4 | NA | | Buffi et al., 2017 [45] | 17 | Adult | Benign | 12-Previous ureteral surgery
1-Iatrogenic
4-Primary congenital | 178 | 3-Fever | 24 | 1-Recurrence stricture | | Raheem et al., 2017 [47] | 1 | Adult | Malignant | UTUC (pT3 with CIS) | 100 (60) | None | NA | NA | | Campi et al., 2019 [46] | 15 | Adult | Malignant | UTUC (5<pT2, 7-pT2, and 3-pT3) | 140 | 4-Clavien 1
2-Clavien 2
2-Clavien 3a | 21 | 4-Intravesical
3-Ipsilateral ureteral tract |
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Summary of articles on ureteroureterostomy during robot-assisted ureteral reconstruction.
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| Study | No. of patients | Pediatric/adult | Benign/malignant disease | Bowel anastomosis (intracorporeal/extracorporeal) | Total operative time (min) | Complication | Follow-up (month) | Recurrence (in case of malignant disease) | | Wagner et al., 2008 [49] | 1 | Adult | Benign-stone | Extracorporeal | 540 | None | 48 | None | | Brandao et al., 2014 [50] | 1 | Adult | Benign-stone | Intracorporeal | 420 | None | 48 | None | | Koenig et al., 2016 [74] | 1 | Pediatric | Benign-neoplasm | Intracorporeal | 600 | None | 4 | None | | Chopra et al., 2016 [75] | 3 | Adult | 2-Benign
1-Malignant | Intracorporeal | 470 (mins in average) | 1-Small bowel necrosis (Ⅳ) | 22.3 (in average) | 1 | | Ubrig et al., 2018 [76] | 7 | Adult | Benign | Intracorporeal | 328 | 2-Ileus (Ⅱ)
1-Pyeloileal stricture (Ⅲ) | 3 | 1 | | Kumar et al., 2019 [77] | 1 | Adult | Benign | Intracorporeal | 270 | None | 6 | None |
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Summary of articles on robot-assisted ileal ureteral reconstruction.
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