Is Pediatric Robotic Surgery viable in resource limited settings? Our experience with Robotic Pyeloplasty
Vidhya Tamizhvanan, MBBS, DNB (Pediatric Surgery), Fellow Ped Urology.
Apollo Children's hospital, Chennai, India, Chennai, India.
BACKGROUND : We live in a country with inequitable distribution of healthcare resources. When a dedicated pediatric robotic program was launched in 2013 in our hospital, we did not expect any takers for this new and expensive technology. We were therefore surprised when we completed 276 procedures in a 6 year period. To find out how effective we were, the records of 164 children who had undergone robot assisted laparoscopic pyeloplasty (RALP) were reviewed. METHODS : Out of 164 records, 145 children had completed at least one year followup and were deemed fit for analysis. Outcomes evaluated included ultrasound resolution of pelvicalyceal (pcs) dilatation, drainage and function in nuclear medicine studies and complications. RESULTS : Mean age of our cohort was 4.8yrs (1mon-17yrs), average console time was 76min (40-180min). There were 20 infant pyeloplasties. One horse-shoe kidney with PUJ of one moiety and one PUJ obstruction of the lower moiety of an incomplete duplex were the deviants tackled. Four children underwent redopyeloplasties and eight were noted to have crossing vessels. Average length of hospital stay was 3 days as most of our patients were from other states. 38 children who were evaluated only with ultrasound declined to undergo further studies as there was excellent resolution of pcs dilatation. Of the 105 children who underwent diuretic studies, 74 showed improvement in renal function, 28 were stable and one child with superfunction preop reached normal levels at review. 2 children showed good drainage but a 10% drop in renal function postop. One child underwent an open pyeloplasty in early infancy, had an infection and severe narrowing of the PUJ needing a redo pyeloplasty (done using robotic assistance). The other child was felt to have overestimation of function in the preop scan. Two children (with stable function) had persistent gross calyceal dilatation, though PUJ was patent and dependant. In one child (a redo) the stenting did not make any difference and the other child is yet to be evaluated. Complications were Clavien 2 in 3 children (urinary infection) and 3b in 3 children (lost needle, omental herniation and a renal vein injury which was successfully repaired)CONCLUSION : RALP has become the procedure of choice in our institution and is driven by parental demand in spite of being twice as expensive as the open option. We were surprised at the number of parents willing to pay out of pocket for this minimally invasive modality. Short operative times, early recovery, a low complication rate and
a consistent success rate of more than 96% has made us confident to offer RALP to the children seeking our care. Robotic Surgery has been successfullly adopted even in low and middle income countries.
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