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Original Research (Original Article) 


Nader Alrahili et al, 2020;4(3):718–721.

International Journal of Medicine in Developing Countries

Outcome of robotic pyeloplasty: a single-center experience

Meshal Saleh Almutair1, Abdullah Ali Alaliyah2, Abdulrahman Mohammed Alsuwailim3, Khalid Mohammed Albalawi4, Naif Abdullah Aldhaam5, Maher Saleh Moazin5

Correspondence to: Meshal Saleh Almutair

*College of Medicine, Qassim University, Qassim, Saudi Arabia.

Email: meshal.s.almutair [at] gmail.com

Full list of author information is available at the end of the article.

Received: 12 January 2020 | Accepted: 21 January 2020


ABSTRACT

Background:

Currently, many urological procedures are done robotically. Yet, the use of the robot in pyeloplasty still needs further evaluation as regards safety and efficacy. The current study aimed to evaluate the outcomes of robotic pyeloplasty.


Methodology:

This retrospective study was done at King Fahad Medical City in Riyadh-Saudi Arabia. It reviewed all the patients who underwent robotic (da Vinci) pyeloplasty in 8 years. The success of the procedure was determined by observing preoperative and postoperative improvement of symptoms, the severity of hydronephrosis, and renal function.


Results:

A total of 29 patients, 17 males, and 12 females with the male-to-female ratio of 1.4:1; the mean age was 24.07 ± 13.435. The mean operative time was 232.86 ± 76.77 minutes. Mean hospital stay was 4.10 ± 3.1 days. Mean blood loss was 54.66 ± 56.54 ml. Follow up results revealed that two cases (6.9%) needed revision, and there were no intraoperative or postoperative complications.


Conclusion:

The use of the robot in pyeloplasty is safe, effective, and has minimal complications.


Keywords:

Robotic, pyeloplasty, outcomes, King Fahad Medical City.


Introduction

The medical field is continuously getting advantage of evolving technology. Nowadays, many urological procedures are done robotically, and many studies have compared in several aspects between the use of robotic and non-robotic surgeries in the urological field, including pyeloplasty, partial nephrectomy, adrenalectomy, nephroureterectomy, fistula repair, and ureteric re-implant [17]. The advantages of robotic pyeloplasty for patients are including a shorter hospital stay, less estimated blood loss, less narcotic pain requirement, and better cosmetic results. Also, the use of robotic surgery decreases the learning curve which could result in more available trained physicians and consequently making the procedures more accessible for patients [812]. Although robotic surgeries are costly and could make the operative time a bit longer, it improves the ergonomics of surgeons and makes their life easier, especially when dealing with difficult patients; and this could reflect on the outcomes. Additional worth mentioning advantages that the robotic surgery offers for surgeons include: enhancing vision and precision, preventing the articulation of instruments, making the dissection and suturing easier, and reduce or eliminate the effect of hands tremor during the procedure [816]. The King Fahad Medical City has started the robotic surgery acquired a da Vinci surgical robot since many years, herein we shared the experience and report the outcomes of all the robotic pyeloplasty cases that had been done including; the hospital stay, revision need, pathological postoperative pain, type, and rate of complications.


Subjects and Methods

This is a cross-section study conducted at King Fahad Medical City. The targeted patients are those who underwent robotic pyeloplasty between 2010 and 2018. The data were collected during July 2018, then it analyzed by Statistical Package for the Social Sciences version 23. Patients who primarily indicated for robotic pyeloplasty then converted to open pyeloplasty (due to active bleeding or approach difficulty) were excluded from the study. The needed data are as follows: indication (symptomatic or due to reduction in renal function), pathological reason either stenosis or presence of crossing vessels, severity of hydronephrosis preoperatively and postoperatively (determined by CT or Ultrasound), whether the obstruction is intrarenal or extrarenal, preoperative and postoperative MAG3 Lasix renal scan/Nuclear scan (T-Half and split renal function), operative time, hospital stay, blood loss, pelvic intraoperative reduction, revision need, and its cause, including intrarenal obstruction, progression of hydronephrosis, technical challenges or disease recurrence, and if there was any new complaint postoperatively, including the complications (e.g., hernia, infection, wound discharge, or dehiscence) and pathological postoperative pain. The success of the procedure was determined by the mean and standard deviation of hospital stay, operative time, and blood loss. Also through follow-up results, the successfulness of the procedure was determined by comparing between preoperative and postoperative hydronephrosis; using Wilcoxon Signed Ranks Test, comparing between preoperative and postoperative nuclear scan findings: (split kidney function and T-half) using Paired T-test, the rate of revision need and its causes, the rate of postoperative complications (hernia, infection, wound discharge, or dehiscence), and the rate of pathological postoperative pain.


Results

This study was done on 29 patients, 17 males (58.6%) and 12 females (41.4%); with the mean age 24.07 ± 13.435 (25.29 ± 15.87 males, and 22.33 ± 9.36 females). All cases indicated for the surgery through presenting symptoms, except for two patients who showed no symptoms. The mean operative time is 232.86 ± 76.77 minutes. The mean of long hospital stay is 7.88 ± 3.87 days. While the mean of common hospital stay is 2.6 ± 0.5 days. The mean blood loss is 54.66 ± 56.54 ml. There were 11 patients (37.9%) with pathological postoperative pain, while 18 patients (62.1%) had no postoperative pain. The most frequent pathological reason is stenosis (58.6%), followed by crossing vessels (41.4%). The site of pathology is more in the right kidney (52%) than in the left kidney (48%). The site of obstruction is extra-renal in all the cases. Follow-up results revealed that only two cases (6.9%) who need revision, while the rest 27 patients had no revision need (93.1%), and all cases went well without complications. The assessments of hydronephrosis are done at the time of presentation (preoperative) and in the follow-up on three visits using ultrasound, the first visit (V1) is after 2 months from the operation, the second visit (V2) is after 6 months, and in third visit (V3) is after 12 months. The analysis by using the Wilcoxon Signed Ranks Test showed that the difference between the severity of hydronephrosis in preoperative and V1, preoperative and V2 are significant (p = 0.009, 0.033, respectively). While the difference in the severity of hydronephrosis preoperative and V3 (p = 0.131), V1 and V2 (p = 1.00), V1 and V3 (p = 1.00), and V2 and V3 (p = 1.00) are not significant (Table 1). In the assessment of kidneys clearance using a nuclear scan, the data showed that there is a significant difference between T-half in the preoperative and V2 in the affected kidney (p = 0.012). Although there was a clinical improvement, however, there were no statistically significant in T-half of preoperative and V1, and between V1 and V2 (p = 0.714, p = 0.897, respectively) as shown in Table 2. The nuclear scan also showed that the difference between split renal function of preoperative (46.17 ± 13.80) and V1 (44.13 ± 16.1), preoperative (46.3 ± 15.2) and V2 (44.52 ± 18.3), and between V1 (40.69 ± 19.00) and V2 (42.6 ± 18.90) were not statistically significant (p = 0.442, 0.679, 0.253, respectively) as shown in Table 3.

Table 1. Comparing between severity of hydronephrosis according to Wilcoxon Signed Ranks Test.

Number p-value
Pre-operative and first visit post-operative 29 0.009
Pre-operative and second visit post-operative 19 0.033
Pre-operative and third visit post-operative 14 0.131
First and second visits post-operative 19 1.00
First and third visits post-operative 14 1.00
Second and third visits post-operative 14 1.00

Discussion

Open pyeloplasty has been the standard for managing ureteropelvic junction obstruction [17,18]. To reduce the morbidity associated with open pyeloplasty, the minimally invasive procedures have been developed, including endoscopic, laparoscopic, and robotic approaches. The advantages of robotic procedures over the previously mentioned procedures are enhancing vision and precision, preventing the articulation of instruments, making the dissection and suturing easier, and reduce or eliminate the effect of hands tremor during the procedure [816]. Additional worth mention advantage is less hospital stay in robotic pyeloplasty when compared with open pyeloplasty, the retrospective study done by Martin Salo et al. [19], showed that the mean length of hospital stay was less in the robotic pyeloplasty (3.4 days) when compared with open pyeloplasty (4.4 days). While in this study, the mean length of hospital stay is divided into two groups: mean length of common hospital stay which is 2.6 ± 0.5 days but mean length of long hospital stay which is 7.88 ± 3.87 days, and that is because of social problems; as the patients think with longer hospital stay the better care and outcome. The mean of operative time is 232.86 ± 76.77 minutes In the comparison between open, laparoscopic, robotic pyeloplasty, it is much longer in robotic pyeloplasty as one study on a large population revealed that the robotic pyeloplasty was the longest operative time [20]. However, in a meta-analysis study that compared robotic-assisted pyeloplasty with conventional laparoscopic pyeloplasty for the treatment of ureteropelvic junction obstruction. Among eight studies, three showed that the mean of operative time was the same in both robotic-assisted pyeloplasty and conventional laparoscopic pyeloplasty, while four studies indicated that the mean of operative time was shorter in robotic-assisted pyeloplasty compared with conventional laparoscopic pyeloplasty and only one prospective study revealed that the conventional laparoscopic pyeloplasty operative time was significantly shorter than robotic-assisted pyeloplasty time [21], this finding could suggest that the short learning curve for robotic pyeloplasty. Moving to follow up results, this study revealed that 27 patients had no revision need (93.1%), while only 2 patients (6.9%) who need revision because of progression of hydronephrosis and one of them had symptoms recurrence. Also, all cases went well without complications including during operation and postoperative (infection, discharge, dehiscence, and hernia). The complication rate is almost the same in open, laparoscopic, and robotic pyeloplasty as a meta-analysis study and two other studies revealed [1922]. One of the most important limitations in this study is the irregular follow up of patients to do an ultrasound to detect the degree of hydronephrosis and nuclear scan to detect the T-half and split kidney function of affected kidneys after robotic pyeloplasty. Also, the sample of this study is small.

Table 2. Mean ± SD and difference in T-half according to paired t-test.

Pre-operative Post-operative first visit Pre-operative Post-operative second visit Post-operative first visit Post-operative second visit
Mean ± SD 15.77 ± 17.58 17.5 ± 14.4 10.75 ± 16.33 29.05 ± 18.2 24.46 ± 21.5 25.6 ± 18.67
Number 17 10 12
p-value 0.714 0.012 0.897

Table 3. Mean ± SD and difference in split kidney function according to paired t-test.

Pre-operative First visit Post-operative Pre-operative Second visit Post-operative First visit Post-operative Second visit Post-operative
Mean ± SD 46.17 ± 13.80 44.13 ± 16.1 46.3 ± 15.2 44.52 ± 18.3 40.69 ± 19.00 42.6 ± 18.90
Number 19 12 13
p-value 0.442 0.679 0.253

Conclusion

This study shows that the use of the robot in pyeloplasty is safe with minimal complications, good effect, few revision need, and few pathological postoperative pain, but it requires long operative time. Many studies are needed for evaluating the overall cost and patient satisfaction with a large sample.


Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from all the participants.


Ethical approval

Ethical approval was granted by Institutional Review Board via reference number 18-368 dated: July 30, 2018.


Author details

Meshal Saleh Almutair1, Abdullah Ali Alaliyah2, Abdulrahman Mohammed Alsuwailim3, Khalid Mohammed Albalawi4, Naif Abdullah Aldhaam5, Maher Saleh Moazin5

  1. College of Medicine, Qassim University, Qassim, Saudi Arabia
  2. College of Medicine, King Khalid University, Abha, Saudi Arabia
  3. College of Medicine, King Faisal University, Hofuf, Saudi Arabia
  4. College of Medicine, Tabuk University, Tabuk, Saudi Arabia
  5. Division of Urology, Department of Surgical Specialties, Main Hospital King Fahad Medical City, Riyadh, Saudi Arabia

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How to Cite this Article
Pubmed Style

Almutair MS, Alaliyah AA, Alsuwailim AM, Albalawi KM, Aldhaam NA, Moazin MS. Outcome of robotic pyeloplasty: a single-center experience. IJMDC. 2020; 4(3): 718-721. doi:10.24911/IJMDC.51-1578837642


Web Style

Almutair MS, Alaliyah AA, Alsuwailim AM, Albalawi KM, Aldhaam NA, Moazin MS. Outcome of robotic pyeloplasty: a single-center experience. http://www.ijmdc.com/?mno=81660 [Access: March 29, 2020]. doi:10.24911/IJMDC.51-1578837642


AMA (American Medical Association) Style

Almutair MS, Alaliyah AA, Alsuwailim AM, Albalawi KM, Aldhaam NA, Moazin MS. Outcome of robotic pyeloplasty: a single-center experience. IJMDC. 2020; 4(3): 718-721. doi:10.24911/IJMDC.51-1578837642



Vancouver/ICMJE Style

Almutair MS, Alaliyah AA, Alsuwailim AM, Albalawi KM, Aldhaam NA, Moazin MS. Outcome of robotic pyeloplasty: a single-center experience. IJMDC. (2020), [cited March 29, 2020]; 4(3): 718-721. doi:10.24911/IJMDC.51-1578837642



Harvard Style

Almutair, M. S., Alaliyah, . A. A., Alsuwailim, . A. M., Albalawi, . K. M., Aldhaam, . N. A. & Moazin, . M. S. (2020) Outcome of robotic pyeloplasty: a single-center experience. IJMDC, 4 (3), 718-721. doi:10.24911/IJMDC.51-1578837642



Turabian Style

Almutair, Meshal Saleh, Abdullah Ali Alaliyah, Abdulrahman Mohammed Alsuwailim, Khalid Mohammed Albalawi, Naif Abdullah Aldhaam, and Maher Saleh Moazin. 2020. Outcome of robotic pyeloplasty: a single-center experience. International Journal of Medicine in Developing Countries, 4 (3), 718-721. doi:10.24911/IJMDC.51-1578837642



Chicago Style

Almutair, Meshal Saleh, Abdullah Ali Alaliyah, Abdulrahman Mohammed Alsuwailim, Khalid Mohammed Albalawi, Naif Abdullah Aldhaam, and Maher Saleh Moazin. "Outcome of robotic pyeloplasty: a single-center experience." International Journal of Medicine in Developing Countries 4 (2020), 718-721. doi:10.24911/IJMDC.51-1578837642



MLA (The Modern Language Association) Style

Almutair, Meshal Saleh, Abdullah Ali Alaliyah, Abdulrahman Mohammed Alsuwailim, Khalid Mohammed Albalawi, Naif Abdullah Aldhaam, and Maher Saleh Moazin. "Outcome of robotic pyeloplasty: a single-center experience." International Journal of Medicine in Developing Countries 4.3 (2020), 718-721. Print. doi:10.24911/IJMDC.51-1578837642



APA (American Psychological Association) Style

Almutair, M. S., Alaliyah, . A. A., Alsuwailim, . A. M., Albalawi, . K. M., Aldhaam, . N. A. & Moazin, . M. S. (2020) Outcome of robotic pyeloplasty: a single-center experience. International Journal of Medicine in Developing Countries, 4 (3), 718-721. doi:10.24911/IJMDC.51-1578837642