Robot-assisted Laparoscopic Orchiopexy: A Comparative Analysis to Laparoscopic Orchiopexy

doi:10.21203/rs.3.rs-2082205/v1

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Research Article

Robot-assisted Laparoscopic Orchiopexy: A Comparative Analysis to Laparoscopic Orchiopexy

https://doi.org/10.21203/rs.3.rs-2082205/v1

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Background

While undescended testes are relatively common, the nonpalpable testis remains a challenging problem. The gold standard treatment remains the laparoscopic orchiopexy. However, today robot-assisted surgery has challenged traditional laparoscopy in many areas of urology. Yet the value of this new approach remains controversial, given concerns with operative time and cost. We reviewed our contemporary results of both robot-assisted orchiopexy (RALO) and traditional laparoscopic orchiopexy (TLO). Our primary aim was to retrospectively compare operative time and cost. We also assessed complications and success rate.

Methods

In this study, all patients treated with laparoscopic and robot-assisted laparoscopic orchiopexy from April 2017 to January 2022 were reviewed using CPT code 54692. Exclusion criteria included bilateral concomitant orchiopexy or concomitant “major surgery.” Also excluded were 1st stage orchiopexies. Patient demographics, surgical operative notes and documentation were all reviewed.

Results

After exclusion criteria was applied, 24 and 22 remained in the laparoscopic and robot-assisted cohorts, respectively. The median operative time in the TLO group was 71 minutes, compared to 102 minutes in the RALO group (Fig. 1) (p > 0.0001). When comparing hospital charges, the TLO group was lower at $38,829, compared to $46,197 in the RALO group (Fig. 2) (p = 0.0069). There was one postoperative complication in the TLO group (localized wound infection), compared to zero in the RALO group.

Conclusions

The robot-assisted orchiopexy is safe and effective. However, at this time it remains more costly in terms of time and resources.

Level of Evidence Level III

cryptorchidism

intrabdominal testis

laparoscopy

robot-assisted surgery

Undescended testes remain a common consult. In particular, the nonpalpable testis provides a unique surgical challenge. This situation requires determining the position of the testis if it is present. Diagnostic laparoscopy remains the gold standard for identifying the presence and location of a nonpalpable testis. Traditionally, laparoscopic orchiopexy has been performed in the same setting if a testis is present within the abdomen ¹. As with other surgeries involving delicate structures, the traditional laparoscopic approach to orchiopexy is technically challenging. Today, with a shift in case volume from traditional laparoscopy toward robot-assisted laparoscopic surgery, conversely younger surgeons are increasingly less experienced with traditional laparoscopy, and more comfortable with the da Vinci platform both in urology, and even pediatric surgery ^2–4. However, the integration of robotics into urology residency programs is not yet formalized ⁵.

For nonpalpable testes, diagnosis and subsequent therapeutic intervention shifted toward laparoscopy in the 1970s, and 1990s, respectively ^6–8. The pediatric urologic community has refined the laparoscopic technique. However, controversies remain regarding the role of one versus two stage Fowler-Stephens orchiopexy and the potential role of the Shehata technique ^9–11. Regardless, laparoscopy remains the gold standard for diagnosis and treatment of the viable, intrabdominal testis.

More recently, robot-assisted surgery has begun to play an larger role in urologic surgery. Within adult urologic surgery, robot-assisted surgery has supplanted laparoscopic surgery in prostate and renal surgery ¹². In the pediatric realm, robot-assisted surgery has also become increasingly common. This has been best demonstrated in the shift in technique for pyeloplasty. This shift from traditional laparoscopy toward the da Vinci™ system has been reflected in trainee experience. Yet, detractors point out that the benefits of robot -assisted urologic surgery have oftentimes been overstated or a tradeoff with unique downsides, specifically in the pediatric arena. ^13,14. With an increasing sensitivity toward surgical costs, some have questioned the value of this technology’s adoption^15,16. As with any new surgical technology, the urologic community is learning what operative goals are best approached with robot-assistance.

At our institution, with one seasoned laparoscopic surgeon and two younger surgeons familiar with robot-assisted surgery, we have developed concomitant cohorts of traditional laparoscopic orchiopexy (TLO) and robot-assisted laparoscopic orchiopexy (RALO). More specifically, we sought to retrospectively compare operative time, need for Fowler-Stephens utilization, and complication rates between the two groups. This was done retrospectively. A secondary aim was to examine comparative hospital charges between these two cohorts. To our knowledge, this is the first large series examining the efficacy and safety of robot-assisted orchiopexy (RALO).

Operative Steps for Robot-assisted Laparoscopic Orchiopexy

An exam under anesthesia was performed to search for a testis in the groin. If a testis remained nonpalpable, a diagnostic laparoscopy via a 5 mm umbilical port was performed to identify if a testis was present within the abdomen. If a viable, intrabdominal testis was noted, two additional 8 mm robotic ports were placed, roughly in a straight line with the now 8 mm robotic, umbilical port, perpendicular to the internal ring of the side of interest. After docking the robot, the testis’ vessels, vas deferens, and adjacent anatomy were identified. The gubernaculum was divided, and used as a handle to manipulate the testis. The posterior peritoneum was then lifted off the testicular vessels so the vessels can be mobilized as proximally as possible. The medial extent of the vas deferens was also mobilized along with a wide leaflet of associated peritoneum. At this point, the surgeon decided whether a Fowler-Stephens procedure is necessary, based upon the testis’ tension due to the gonadal vessels. If proceeding in one stage, a transcrotal port was placed medial to the inferior epigastric, and a laparoscopic grasper was used to relocate the testis in the dependent part of the scrotum. For a video representation our approach, please refer to Higganbotham et al ¹⁷.

Study Design

After obtaining institutional IRB approval at our institution, all consecutive patients treated at our tertiary, children’s hospital for a viable intrabdominal testis via CPT code 54692 were collected from April 2017 to January 2022. This code encompasses all laparoscopic (TLO) and robot-assisted laparoscopic orchiopexies (RALO). One surgeon at our instituation only performed TLO, and two others only performed RALO on all intrabdominal testes. We collected general demographic data, operative time, any and all postoperative complications, and any/all hospital charges associated with each patient’s orchiopexy. Exclusion criteria included bilateral concomitant orchiopexy or concomitant “major surgery.” Also excluded were 1st stage orchiopexies. We defined “major surgery” as requiring > 30 minutes and/or another surgical service. Examples included gastrostomy tube placement or contralateral inguinal hernia repair. Follow up was documented from the electronic medical record. For those not seen for an extended period of time, a phone call was attempted to family to discuss the patient.

Operative charges were collected from the hospital. Charges were subdivided by equipment charges, anesthesia charges, and facility/operating room charges. The latter two were positively correlated with operative time. Equipment charges included the cost of disposable equipment, one tenth (1/10th ) of the cost for any used robotic instrument (given their use). Importantly the costs of ownership of the da Vinci system, including acquiring the system, depreciation costs, and maintenance costs, were excluded, but these costs were also not included in the charges for any particular case.

Study Analysis

For analysis, the TLO and RALO cohorts were compared using a contemporary version of Microsoft Excel. A standard t-test was used when appropriate to compare the TLO and RALO cohorts in all continuous variables, and assess for statistical significance.

From April 2017 to January 2022, a total of 29 traditional laparoscopic orchiopexies (TLO), and 28 robot-assisted orchiopexies (RALO) were collected. Of the 29 TLOs performed, 5 surgeries were excluded, two for being first stage procedures, two for being bilateral procedures, one for complex concomitant procedure. This left 24 TLO cases to be reviewed. Five of the surgeries had a circumcision performed at the same time for which time was subtracted for the operative time. Of the 28 RALOs performed, six surgeries were excluded. Two were excluded for being first stage procedure, one for being bilateral and two for concomitant “major” procedures, and one for orchiectomy due to vasal injury during second stage FS. This left 22 robot-assisted orchiopexies to be analyzed. Five of the 22 included surgeries had an additional procedure performed at the same time for which time was subtracted from the operative time.

Both groups were roughly similar in age, race, insurance status and complications (Table 1). However, the Fowler-Stephens procedure was utilized less frequently in the traditional laparoscopic group (3 procedures, 13%) as compared to the robot-assisted group (10 procedures, 45%). No testis was noted to be atrophic upon follow up. Follow up was also reviewed. The one postoperative complication was a patient in the TLO group who developed a wound infection in the scrotum requiring oral antibiotics. One of the excluded RALO patients mentioned above had a long-looping vas deferens that was injured during incision of the gubernaculum. This was unfortunate, not due to the technique, but rather surgeon inexperience.

Table 1

Demographics of Patients
Demographic	Laparoscopic	Robotic
Number of testicular units	24	22
Median Age (IQR)	1.3 years (0.92–1.8)	1.16 years (0.85–1.69)
Medicaid (Percentage)	13 (54%)	16 (73%)
Race (Percentage)	19 White (79%)	16 White (73%)
	5 Other (21%)	6 Other (27%)
Fowlers-Stephens Utilization	3 (13%)	10 (45%)
Median Follow Up (IQR)	1085 days (51-1330)	68 days (242–915)
Complications	1	0
P < 0.0001
*Of note, this excludes the upfront costs sustained by the hospital to purchase the da Vinci system.
P = 0.0021

We first compared the two groups in regards to operating room time. The median and mean times for the TLO group were 71 and 70 minutes, respectively (Fig. 1). This was less than the RALO group with a median and mean time of 102 and 105 minutes, respectively. We found this difference to be statically significant (p > 0.0001).

In regards to hospital charges, we also saw relatively higher charges in the RALO group. For the TLO group, the median and mean total charges were $38,829 and $40,269, respectively (Fig. 2). For the RALO group, the median and mean total cost were $46,197 and $46,431, respectively. This difference was statistically significant (p = 0.0069). In both groups, general operating room charges were the predominant charge, contributing to an overall higher charge in the RALO group. Interestingly, instrument charges were lower in the RALO group, but this was a smaller component overall, and did not make up for the significantly higher operating room charges in that group.

Given that RALO was new to both our surgeons and operating room, we analyzed how operating room time and charges changed over time in the included procedures (Fig. 3 and Fig. 4). Case length and charges significantly varied amongst cases, but when applying a best fit line, we saw a slight increase in operating room time, and charges over time.

Robot-assisted laparoscopic orchiopexy (RALO) is a new and alternative way to approach the intrabdominal testis. It appears to be safe with a low complication rate. However, operating room time and charges seem to be significantly more with this approach, as compared to the traditional laparoscopic orchiopexy (TLO).

This study suggests that the RALO approach to the intrabdominal testis is safe, but remains more time intensive and costly. Most recently, Shumaker and Neheman published their series of Robot-assisted Modified One-Stage Orchiopexy ¹⁸. Here, they describe their technique, which was very similar to ours, however, all patients had a single stage orchiopexy. In addition, they described an operative time of 97 minutes (IQR 77.5-109.5). This was very similar to our RALO operative time of 105 minutes (IQR 91.5–113). Our cohort was more varied, with 5/23 (21.7%) being 2nd stage Fowler Stephens orchiopexies, and 14/23 (60.9%) being a single stage orchiopexy without Fowler Stephens. Only 4/23 (17.4%) were single stage FS, robot-assisted orchiopexies. 1st Stage orchiopexies were excluded from our analysis.

Our study has limitations. The distance between the internal ring and the testis was not consistently defined in reviewed operative reports. In addition, both TLO and RALO cohorts were varied in the approach. Fowler Stephens was not used consistently, and some patients were staged. With that said, both cohorts were relatively small, making durable comparisons difficult. As stated above, all TLOs were performed by an experienced pediatric, laparoscopic surgeon, while RALOs were a new approach. This may have contributed to longer operative time due to surgeons and OR staff adjusting to a new procedure using the robot. The magnitude of this bias is difficult to assess.

However, we feel this study provides meaningful data as to the feasibility of the robot-assisted orchiopexy. There has not been a cohort of this size reporting RALO results, especially compared to traditional laparoscopy. Although this approach was more time intensive and costly, one could argue that with larger numbers and experience, the gap could narrow with traditional laparoscopy, much like other urologic reconstructive procedures. ³ Further, with skill sets shifting, younger pediatric urologists are inevitably applying the robotic skill set to urologic problems, pediatric and adult alike. Further study remains necessary to see where the robotic platform is superior or inferior to the “gold standard” approach.

Recently, Mark Tyson published a telling take upon the comparisons between robotic cystectomy and the open approach ¹⁹. He notes the robotic approach was associated with less blood loss and hospital length of stay. Yet, it was found to require more operative time and operating room expenditures. However, we must understand that the current robotic platform, the da Vinci, is merely a tool, and a stepping stone toward more advanced, and potentially beneficial technology for our patients. Regardless, the da Vinci platform melds the minimally invasive approach of laparoscopic surgery with the favorable learning curve of open surgery with intuitive, approachable Endowrist (Intutive Surgical, Inc., Sunnyvale, Calif) technology, motion scaling, tremor filtering, and enhanced three-dimensional viewing. One can expect further iterations of robotic surgical technology to build upon these advantages in the future.

Robot-assisted orchiopexy (RALO) is a safe and effective approach to the intrabdominal, viable testis. We present the first large series with this new approach. Further prospective studies via multiple institutions are required comparing RALO and TLO to more objectively assess the value of the RALO in the pediatric urology armamentarium.

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Table 1: Demographics of Patients

Demographic	Laparoscopic	Robotic
Number of testicular units	24	22
Median Age (IQR)	1.3 years (0.92-1.8)	1.16 years (0.85-1.69)
Medicaid (Percentage)	13 (54%)	16 (73%)
Race (Percentage)	19 White (79%)	16 White (73%)
	5 Other (21 %)	6 Other (27%)
Fowlers-Stephens Utilization	3 (13 %)	10 (45%)
Median Follow Up (IQR)	1085 days (51-1330)	68 days (242-915)
Complications	1	0

No competing interests reported.

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Robot-assisted Laparoscopic Orchiopexy: A Comparative Analysis to Laparoscopic Orchiopexy

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Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Materials And Methods

Operative Steps for Robot-assisted Laparoscopic Orchiopexy

Study Design

Study Analysis

Results

Discussion

Conclusions

References

Tables

Additional Declarations

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