title: Ninety-day perioperative complications of pediatric robotic urological surgery: A multi-institutional study.
abstract: BACKGROUND
  Robotic technology is the newest tool in the armamentarium for minimally invasive surgery. Individual centers have reported on both the outcomes and complications associated with this technology, but the numbers in these studies remain small, and it has been difficult to extrapolate meaningful information.
  
  
  OBJECTIVE
  The intention was to evaluate a large cohort of pediatric robotic patients through a multi-center database in order to determine the frequency and types of complications associated with robotic surgery for pediatric reconstructive and ablative procedures in the United States.
  
  
  METHODS
  After institutional review board approvals at the participating centers, data were retrospectively collected (2007-2011) by each institute and entered into a RedCap(®) database. Available demographic and complication data that were assigned Clavien grading scores were analyzed.
  
  
  RESULTS
  From a cohort of 858 patients (880 RAL procedures), Grade IIIa and Grade IIIb complications were seen in 41 (4.8%); and one patient (0.1%) had a grade IVa complication. Intraoperative visceral injuries secondary to robotic instrument exchange and traction injury were seen in four (0.5%) patients, with subsequent conversion to an open procedure. Grade I and II complications were seen in 59 (6.9%) and 70 (8.2%) patients, respectively; they were all managed conservatively. A total of 14 (1.6%) were converted to an open or pure laparoscopic procedure, of which, 12 (86%) were secondary to mechanical challenges.
  
  
  CONCLUSIONS
  It is believed that this study represents the largest and most comprehensive description of pediatric RAL urological complications to date. The results demonstrate a 4.7% rate of Clavien Grade IIIa and Grade IIIb complications in a total of 880 cases. While small numbers make it difficult to draw conclusions regarding the most complex reconstructive cases (bladder diverticulectomy, bladder neck revision, etc.), the data on the more commonly performed procedures, such as the RAL pyeloplasty and ureteral reimplantation, are robust and more likely represent the true complication rate for these procedures when performed by highly experienced robotic surgeons.
  
  
  CONCLUSIONS
  Pediatric robotic urologic procedures are technically feasible and safe. The overall 90-day complication rate is similar to reports of laparoscopic and open surgical procedures.
  
  
  RESULTS
  n (%) Life threatening (IVa): 1 (0.1%) Requiring radiologic and or surgical intervention (IIIa and IIIb): 41 (4.8%) Secondary to robotic system: 4 (0.5%) Mechanical failure leading to conversion: 14 (1.6%).
authors.affiliation: Division of Pediatric Urology, Children's Hospital of Pittsburgh, The University of Pittsburgh Medical Center, 4106 Fourth Floor Faculty Pavilion, 1 Children's Hospital Drive, 4401 Penn Avenue, Pittsburgh, PA 15224, USA. Electronic address: pankajdangle@gmail.com.
authors.forename: P P
authors.initials: PP
authors.lastname: Dangle
authors.affiliation: Pediatric Minimally Invasive and Robotic Surgery, James Buchanan Brady Urological Institute, Johns Hopkins Hospital 1800 Orleans Street, Bloomberg 7308-B, Baltimore, MD 21287, USA.
authors.forename: A
authors.initials: A
authors.lastname: Akhavan
authors.affiliation: Department of Family Medicine and Public Health, University of California, San Diego, 9500 Gilman Drive, Mail Code #0811, La Jolla, CA 92093, USA.
authors.forename: M
authors.initials: M
authors.lastname: Odeleye
authors.affiliation: Department of Urology, Seattle Children's Hospital, P.O. Box 5371, Seattle, WA 98145-5005, USA.
authors.forename: D
authors.initials: D
authors.lastname: Avery
authors.affiliation: Department of Urology, Seattle Children's Hospital, P.O. Box 5371, Seattle, WA 98145-5005, USA.
authors.forename: T
authors.initials: T
authors.lastname: Lendvay
authors.affiliation: Division of Pediatric Urology, Texas Children's Hospital/Baylor College of Medicine, 6701 Fannin St Ste 620, Houston, TX 77030, USA.
authors.forename: C J
authors.initials: CJ
authors.lastname: Koh
authors.affiliation: Vattikuti Urology Institute, Henry Ford Hospital, 2799 West Grand Blvd., Detroit, MI 48202, USA.
authors.forename: J S
authors.initials: JS
authors.lastname: Elder
authors.affiliation: Department of Minimally Invasive Surgery, Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 5037, Cincinnati, OH 45229-3039, USA.
authors.forename: P H
authors.initials: PH
authors.lastname: Noh
authors.affiliation: Department of Minimally Invasive Surgery, Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 5037, Cincinnati, OH 45229-3039, USA.
authors.forename: D
authors.initials: D
authors.lastname: Bansal
authors.affiliation: Department of Minimally Invasive Surgery, Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 5037, Cincinnati, OH 45229-3039, USA.
authors.forename: M
authors.initials: M
authors.lastname: Schulte
authors.affiliation: University of Minnesota School of Medicine, Minneapolis, MN, USA.
authors.forename: J
authors.initials: J
authors.lastname: MacDonald
authors.affiliation: Division of Pediatric Urology, 3rd Floor Wood Center, Children's Hospital of Philiadelphia, 34th Street and Civic Center Blvd, Philadelphia, PA 19104-4399, USA.
authors.forename: A
authors.initials: A
authors.lastname: Shukla
authors.affiliation: Connecticut Children's Medical Center, 282 Washington St., Hartford, CT 06106, USA.
authors.forename: C
authors.initials: C
authors.lastname: Kim
authors.affiliation: Connecticut Children's Medical Center, 282 Washington St., Hartford, CT 06106, USA.
authors.forename: K
authors.initials: K
authors.lastname: Herbst
authors.affiliation: University of Virginia, USA.
authors.forename: S
authors.initials: S
authors.lastname: Corbett
authors.affiliation: Department of Urology, The University of Chicago Medicine & Biological Sciences, 5841 S. Maryland, P-217, MC 7122, Chicago, IL 60637, USA.
authors.forename: J
authors.initials: J
authors.lastname: Kearns
authors.affiliation: Department of Biostatistics, The University of Chicago Medicine & Biological Sciences, 5841 S. Maryland, P-217, MC 7122, Chicago, IL 60637, USA.
authors.forename: R
authors.initials: R
authors.lastname: Kunnavakkam
authors.affiliation: Director Pediatric Urology, Comer Children's Hospital, 5841 S. Maryland, P- 217, MC 7122, Chicago, IL 60637, USA. Electronic address: mgundeti@surgery.bsd.uchicago.edu.
authors.forename: M S
authors.initials: MS
authors.lastname: Gundeti
mesh_terms: D000293:Adolescent; D000328:Adult; D017677:Age Distribution; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D010535:Laparoscopy / Q000009:adverse effects*; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000009:adverse effects*; D017678:Sex Distribution; D014481:United States / Q000453:epidemiology; D014513:Ureter / Q000601:surgery*; D014517:Ureteral Obstruction / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000009:adverse effects* / Q000379:methods; D055815:Young Adult
keywords: Clavien-Dindo grading system; Complication; Multi-institutional; Pediatric; Robotic