Laparoscopic pyeloplasty proficiency during a residency program after adoption of a standardized simulation training program is maintained during the COVID pandemic despite reduced surgery volume

ABSTRACT Purpose: To evaluate the effect of the standardized laparoscopic simulation training program in pyeloplasty, following its implementation and during the COVID-19 pandemic. Material and Methods: A retrospective chart review was performed at Hospital de Clínicas de Porto Alegre, a tertiary referral center in south Brazil, in which 151 patients underwent laparoscopic pyeloplasty performed by residents between 2006-2021. They were divided into three groups: before and after adoption of a standardized laparoscopic simulation training program and during the COVID-19 pandemic. The main outcome was a combined negative outcome of conversion to open surgery, major postoperative complications (Clavien-Dindo III or higher) or unsuccessful procedure, defined as need for redo pyeloplasty. Results: There was a significant reduction in the combined negative outcome (21.1% vs 6.3%), surgical time (mean 200.0 min vs 177.4 min) and length of stay (median 5 days vs 3 days) after the adoption of simulation training program. These results were maintained during the COVID-19 pandemic (combined negative outcome of 6.3%, mean surgical time of 160.1 min and median length of stay of 3 days) despite a reduction in 55.4% of the surgical volume. Conclusion: A structured laparoscopic simulation program can improve outcomes of laparoscopic pyeloplasty during the learning curve.

Multicenter comparative study of open, laparoscopic, and robotic pyeloplasty in the pediatric population for the treatment of ureteropelvic junction obstruction (UPJO)

ABSTRACT Introduction: Dismembered open pyeloplasty described by Anderson and Hynes is the "gold standard" for the treatment of ureteropelvic junction obstruction. The aim of our study was to compare the results of open (OP) vs laparoscopic (LP) vs robotic (RALP) pyeloplasty. Material and Methods: A multicenter prospective review was conducted of pyeloplasty surgeries performed at five high-volume centers between 2014 and 2018. Demographic data, history of prenatal hydronephrosis, access type, MAG3 renogram and differential renal function, surgery time, length of hospital stay, and complication rate (Clavien-Dindo) were recorded. Access type was compared using the Kruskal-Wallis, Chi-square, or Fisher's exact tests. Results: A total of 322 patients were included: 62 OP, 86 LP, and 174 RALP. The mean age was 8.13 (r: 1-16) years, with a statistically significant lower age (mean 5 years) in OP (p < 0.001). There were no significant differences in the distribution of the side affected. Operative time was 110.5 min for OP, 140 min for LP, and 179 min for RALP (p < 0.0001). Hospital stay was significantly shorter in the RALP group than in the other groups (p < 0.0001). There were no differences in postoperative complications and reoperations between the three groups. Conclusions: Minimally invasive surgery for the management of UPJO in children is gaining more acceptance, even in patients younger than 1-year-old. Operative time continues to be significantly shorter in OP than in LP and RALP. Hospital stay was shorter in RALP compared to the other techniques. No differences were found in complication rates, type of complications, and reoperation rate.

Easy, reproducible extraperitoneal pelvic access for robot - assisted radical prostatectomy

ABSTRACT Robot - assisted radical prostatectomy is commonly performed transperitoneally (tRARP), although the extraperitoneal (eRARP) approach is a safe and effective alternative that may be preferred in certain situations. We developed a novel method of direct access into the space of Retzius with a visual obturator port (Visiport™) for laparoscopic or robotic prostatectomy. We present an instructional video of extraperitoneal pelvic access for eRARP with both internal and external camera views. The patient is first placed in lithotomy and 15° Trendelenburg position. The camera is inserted infraumbilically and angled caudally. The pre-peritoneal space is accessed through the anterior rectus fascia using a Visiport™ (Covidien, $ 60 www.esutures.com), and the working space is developed with a kidney - shaped balloon OMSPDBS2™ (Covidien, $ 49 www.esutures.com). After the space is insufflated, subsequent trocars are angled in extraperitoneally under direct vision. The average time from incision to final port placement after a learning curve of about 50 cases is 8 minutes (IQR 7-10). We have performed over 1.000 cases using this technique and eRARP has become our procedure of choice. Our last 500 + cases were performed robotically. Approximately 10% of the time peritoneotomies were noted, but rarely did these require conversion to tRARP. There have been no bowel or other abdominal organ injuries, major vascular or other complications in any of these cases.