Paediatric Surgeon & Urologist Grand Round 17 March 2016 Prakash Mandhan M.D, Ph.D Paediatric Surgeon & Urologist

Laparoscopic Pyeloplasty Robotic Assisted Laparoscopic Pyeloplasty in Children

UPJO and Pyeloplasty Open Pyeloplasty – standard. Associated with pain, long-stay and scar Laparoscopic Pyeloplasty – Great alternative option with less pain, short hospital-stay and also minimal scar Steep learning curve due to difficult intracorporeal suturing in a limited working space

Robot-Assisted Surgery The introduction of robotic surgical system has facilitated precise intracorporeal suturing particularly in small working space and also has greatly reduced the learning curve from simple to complex minimal invasive procedures in children

Why Robot-Assisted Surgery Great - optical magnification EndoWrist Instrumentation and Improved Dexterity Three-dimensional operating view Tremor filtration Enhanced Ergonomics

Robotic Assisted Laparoscopic Pyeloplasty The first RALP series – 2002* *M.T. Gettman, R. Neururer, G. Bartsch, R. Peschel. Anderson-Hynes dismembered pyeloplasty performed using the da Vinci robotic system. Urology. 2002;60:509-513 Since then RALP has been adopted by a number of paediatric surgery and paediatric urology centres around the world Tasian GE, Casale P. The robotic-assisted laparoscopic pyeloplasty: gateway to advanced reconstruction. Urol Clin North Am. 2015 Feb;42(1):89-97.

Robot-Assisted Surgery da Vinci Master-slave robotic platform Surgeon Console Patient-side Cart Endowrist Instruments Vision System

Endowrist Instruments

Robot-Assisted Surgery in Qatar 2010 - Qatar Robotic Surgery Centre QRSC is a training centre for surgeons and nurses to be involved in robot- assisted surgery at HMC QRSC is equipped with three da Vinci training robots, a three-dimensional surgical simulator for MIS training and a tele-mentoring theatre for distance training with experts in other countries

RALP – Instruments & Supplies da Vinci Surgical System 8.5mm 0° telescope 12, 8.5 and 5mm ports Maryland bipolar forceps Monopolar hood devise or curved scissors Robotic needle driver 4/0 monofilament absorbable sutures DJ Stent

Redo Pyeloplasty & RALP Although uncommon, failed pyeloplasty represents a management dilemma and is considered as more challenging because of fibrosis and adhesions in the region of the previously operated UPJ Transperitoneal RAL approach is well suited for these patients as ideally one will encounter minimal intra-abdominal scarring from the previous retroperitoneal mobilisation Robot assisted laparoscopic pyeloplasty in patients of ureteropelvic junction obstruction with previously failed open surgical repair. Hemal AK, Mishra S, Mikharjee S et al: Int J Urol 2008; 15: 744.

RALP - Worldwide

Trainee Interest The interest in developing RAL surgery is ever increasing In a recent survey of ACGME accredited paediatric urology fellowship training, robotic/laparoscopic surgery was among the top 3 subspecialty they wanted to be trained* Role of simulation in robotic surgery for surgeons is growing – various simulators are available for simulation training to assess the skills set in the various tasks *Pediatric urology fellowship training: are we teaching what they need to learn? Wang MH1, Chen B, Kern D, Gearhart S. J Pediatr Urol. 2013 Jun;9(3):318-21

Take Home Message RALP is likely to emerge as the new minimally invasive standard of care whenever robotic technology is available because its precise suturing and shorter learning curve represent unique attractive features. Surgical trainees and young surgeons should be acquitted with this new emerging technology. The major bottleneck in the development of robot surgery is the capital cost. However like all new technical advancements, this will gradually fall to be within reach of the hospitals.