Robot-assisted laparoscopic ureteropelvic junction plasty in children using the da Vinci Xi robotic system: a Russian first experience

Introduction. Robotic pyeloplasty represents the most frequently performed surgical intervention globally utilizing the da Vinci robotic platform in pediatric patients. The present study introduces the initial experience of executing robot-assisted laparoscopic pyeloplasty (RALP) employing the da Vinci Xi robotic system.
Objective. To conduct a comprehensive analysis of the experience in performing RALP in pediatric patients using the da Vinci Xi robotic platform. 
Materials & methods. Between July and October 2024, a total of 14 robot-assisted laparoscopic pyeloplasties (RALP) were successfully performed. The patient cohort consisted of an equal distribution of 7 boys (50%) and 7 girls (50%). The mean anthropometric parameters of the patients were as follows: height 131.2 ± 22.1 cm and body weight 29.7 ± 15.0 kg. The severity of hydronephrosis, assessed using the Society for Fetal Urology (SFU) grading system, revealed that 11 patients (78.5%) presented with SFU grade 3 hydronephrosis, while 3 patients (21.5%) exhibited SFU grade 4 hydronephrosis. The etiology of the ureteropelvic junction obstruction (UPJO) was determined as follows: an UPJO internal cause was identified in 6 patients (43%), whereas an external cause (‘conflict’ vessel) was detected in 8 patients (57%).
All patients underwent robot-assisted dissecting pyeloplasty without reduction resection of the renal pelvis. The surgical procedure was executed with the patient positioned on the side contralateral to the site of obstruction. The laparoscopic access was established using three 8 mm trocars for the insertion of optics and robotic instruments, complemented by a single 5 mm trocar for the assistant’s instrumentation.
Results. No conversions were observed throughout the case series. The operative time demonstrated a significant reduction over the study period: initially, the total operative time was 195 min, which decreased to 110 min by the study’s conclusion. The mean operative time across all cases was 146.7 ± 29.3 min. The docking time exhibited a notable learning curve, decreasing from 60 minutes during the initial stages to an average of 25.0 ± 10.8 min as proficiency improved. Similarly, the console time reduced from 150 min initially to 70 min by the study’s end. The mean console time varied based on the etiology of obstruction: for internal causes of OPUS, it was 82.0 ± 16.0 min, while for external causes, it was 93.0 ± 27.0 min. Postoperatively, only one patient experienced stent dysfunction, which was successfully managed without the need for stent replacement.
Conclusions. The initial experience with RALP reveals a significant advantage over conventional laparoscopic pyeloplasty (LP). Specifically, RALP allows for the preservation of the operator’s physical conditioning throughout the entire process of anastomosis formation. This preservation enables the formation of an anastomosis with maximum precision, thereby eliminating the compromise between the desired quality of intracorporeal suturing and the actual surgical outcome that often occurs due to operator fatigue with laparoscopic access. The current findings indicate that our accumulated two decades of experience in laparoscopic pyeloplasty substantially speeds up mastering the robotic platform. This prior expertise facilitates the optimization of console time duration and enables the rapid attainment of the performance plateau, achieving optimal surgical efficiency in the shortest possible timeframe.

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