Fig. 6.1
Forest plot comparisons of overall success rates for studies comparing RLP vs LP (a) and RLP vs OP (b)
Eight studies reported data for requirement of re-operation due to recurrent PUJO. While overall re-operations rates were lower in RAP vs LP and OP, these did not reach statistical significance (Fig. 6.2).
Fig. 6.2
Forest plot comparisons of re-operating rates for studies comparing RAP vs LP (a) and RAP vs OP (b)
Analysis of complications categorised into sub-groups of minor (Clavien Grade 1–2) and major (Clavien Grade 3–5) events according to the Clavien-Dindo classification identified no significant differences between the RAP vs LP groups, and RAP vs OP groups (P = 0.47–0.88) (Figs. 6.3 and 6.4).
Fig. 6.3
Forest plot comparisons of Clavien Grade 1–5 postoperative complications for studies comparing RAP vs LP (a) and RAP vs OP (b)
Fig. 6.4
Forest plot comparison of EBL for studies comparing RAP vs OP
Pooled analysis showed a significantly shorter overall LOS for RAP by almost one full day (Fig. 6.7b,WMD −0.75 days, 95 % CI–1.28 to–0.22; P = 0.005).
Three studies reported OT for RAP vs LP. Overall, there was a 33 min shorter OT for RAP; however, this was not significant peripheral time for cystoscopy and patient re-positioning.
Conclusion
RLP has emerged as offering the advantages of conventional laparoscopy in terms of perioperative morbidity, but with a more rapid and efficient learning curve, with the potential for superior results based on the enhanced manipulation and visualization.
The main technical benefits of robot-assistance in minimally invasive surgery are consistently attributed towards the more demanding procedural steps, namely the ureteric spatulation, pelvis reduction, and uretero-pelvic anastomosis. The motion-scaled EndoWrist® instruments enable parallel alignment of scissors with the proximal ureter for more accurate and controlled linear spatulation. Similarly, the enhanced manual dexterity with these instruments and stereoscopic vision contribute to a lower degree of difficulty for the challenging task of intracorporeal suturing within small anatomical workspaces. Meta-analysis of the current literature identifies no significant differences between RAP and LP or OP for the five primary outcome variables assessed. Significant differences in favour of RAP were found for secondary outcome variables of EBL (vs OP) and LOS (vs LP and OP). OT was found to be significantly longer for RAP vs OP. Limited evidence from observational studies indicates lower opiate analgesia requirement for RAP (vs LP and OP), higher total costs for RAP vs OP, and comparable costs for RAP vs LP. Given the availability of multiple treatment options, treatment should be tailored to the individual case, which mainly depends on the anatomic conformation of UPJO as assessed pre- and intraoperatively. The adoption of robotic technology, with its precise suturing and shorter learning curve, represents an attractive option for performing minimally invasive surgery, and robotic pyeloplasty is likely to emerge as the new minimally invasive standard of care whenever this technology is available. For both laparoscopy and robotics, the technique can be modulated and tailored to the specific case according to intraoperative findings and personal surgical experience (Figs. 6.5, 6.6, 6.7, 6.8, 6.9, 6.10, 6.11, 6.12, 6.13, 6.14, 6.15, 6.16, 6.17, 6.18, 6.19, 6.20, 6.21, 6.22, 6.23, 6.24, 6.25, 6.26, 6.27, 6.28, 6.29, 6.30, 6.31, and 6.32).
