Laparoscopic, robotic pyeloplasty both effective in utereropelvic junction obstruction

Hamilton, Ontario-Laparoscopic and robotic pyeloplasty appear to be equally effective in correcting utereropelvic junction obstruction, according to research presented at the AUA annual meeting in Chicago.

The major differences between the two approaches are non-clinical, says first author Luis H. Braga, MD, PhD, assistant professor in the department of surgery/urology at McMasters University, Hamilton, Ontario. The laparoscopic approach is a challenging procedure with a steep learning curve. The robot flattens the learning curve by offering us-ers improved three-dimen-sional vision, tremor reduction, motion scaling, extended range of motion in the surgical arms, as well as better ergonomics.

Dr. Braga and his colleagues conducted a meta-analysis of publications on laparoscopic and robotic UPJ obstruction procedures in six languages, but could find only eight studies that met their criteria for inclusion in the analysis.

There is a degree of importance attached to such a study, Dr. Braga says. The robotic technology carries a "new is better" aura, and that may be used as a marketing tool to attract patients to major centers.

"If this technology is proven to be superior, it could be a problem in countries like Canada, where physicians might extend the already-long surgical waiting time by continually referring patients to the few centers that have the robots," he said.

The technology is also expensive. The procedures are costlier, and in an era in which people are no longer counting health care dollars but health care pennies, the costs of establishing robots in institutions competing for health care monies within the same community may not be the best economic path to follow, Dr. Braga adds.

No differences in OR time, success rates

The study conducted by Dr. Braga and his colleagues found no differences between the two procedures in terms of operative times, success rates, or complications. But there were a number of curious differences that could not be explained by the data available to the researchers, forcing them to speculate as to the causes.

The robotic operative time was similar to laparoscopic operative time in centers with large conventional laparoscopic experience, but in centers with limited laparoscopic experience, the laparoscopic procedure took nearly an hour longer. The researchers theorize that the shorter learning curve associated with the robot may give its users an advantage over individuals and institutions just beginning to use the laparoscopic procedure. This advantage is reflected in shorter operative times.

They also found that the robotic OR time was shorter than the laparoscopic OR time in a subgroup of pediatric patients. This puzzled the researchers because configuring robotic arms around a smaller patient is usually time consuming. They speculated that patient size may not have been an issue because the patients in the studies they used were older (between 9 and 12 years of age).

Researchers also found that hospital stays were nearly half a day shorter in patients undergoing the robotic procedure. This finding may be attributable to economic pressures, rather than clinical circumstance, according to Dr. Braga. The laparoscopic procedure is slightly older than the robotic procedure, and the publishing date of early laparoscopic studies substantiate this. The robot was introduced in an era of increased pressure to shorten hospital stays. Thus, the time difference between the two procedures may be more reflective of economic concerns than clinical situations.

Dr. Braga recognizes that the study has a number of limitations, the most important of which is that there were no randomized, controlled trials comparing the two procedures available for incorporation into the study. He says that it is imperative to initiate such a trial and drive it to completion if applications of the technologies are to be driven by clinical, rather than economic considerations.

ModernMedicine NETWORK

EDUCATION
Urologist and legal expert Steve Waxman, MD, JD, discusses the medicolegal pitfalls of laparoscopy-and how to avoid them.See his column at: http://www.urologytimes.com/pitfalls

COMMUNITY
Geoffrey N. Box, MD calls for efficacy studies that compare LESS and NOTES to standard minimally invasive surgery. Read his editorial at: http://www.urologytimes.com/lessmore

NEWS & UPDATES
Comfort level determines whether to perform a pure laparoscopic, hand-assisted, or robot-assisted procedure, a study found. Read about it at: http://www.urologytimes.com/comfortlevel