Mastering the learning curve with quality assurance: Outcomes of robot-assisted ureteral reimplantation in a pediatric cohort.

BACKGROUND

Robot-assisted extravesical ureteral reimplantation (REVUR) is a minimally invasive procedure for treating vesicoureteral reflux (VUR) and obstructive megaureter in children. Compared to traditional open surgery (OS) and laparoscopic surgery (LS), REVUR offers potential advantages in precision during dissection and suturing. However, its learning curve and clinical benefits require further validation within regional medical practice.

OBJECTIVE

This study aimed to compare the perioperative outcomes and efficacy of REVUR, LS, and OS in pediatric patients with VUR or megaureter. Additionally, we used the cumulative sum (CUSUM) control chart to quantitatively analyze the learning curve and surgical quality of REVUR.

METHODS

This single-center retrospective cohort study included children (≤14 years old) who underwent primary ureteral reimplantation between January 2014 and January 2025. Patients were divided into three groups based on surgical technique: the OS group (n = 74, intravesical approach), the LS group (n = 35, intravesical approach), and the REVUR group (n = 53, extravesical approach). The primary outcome was the overall success rate, defined as meeting both radiographic and clinical success criteria. Multivariable regression models adjusted for baseline confounders. For the REVUR group, time-based CUSUM analysis evaluated the learning curve, while failure-based CUSUM charts enabled continuous surgical quality monitoring.

RESULTS

A total of 162 patients were included. After adjusting for confounders-including age, VUR grade, and whether ureteral tapering was performed-no statistically significant differences were observed among the three groups in radiographic success rate (OR = 1.475, P = 0.318), clinical success rate (OR = 0.850, P = 0.744), or overall success rate (OR = 1.070, P = 0.827). However, compared to the OS and LS groups, the REVUR group had a significantly shorter postoperative hospital stay (P < 0.001) and a shorter duration of catheterization (P < 0.001), although total hospitalization costs were significantly higher (P < 0.001). Learning curve analysis indicated that proficiency in REVUR was achieved after approximately 11 cases for non-tapered reimplantation and 9 cases for those requiring tapering. Quality monitoring via CUSUM charts showed that the failure rate remained within an acceptable range (overall failure rate 9.4 %) across 53 consecutive procedures, with the process under statistical control.

CONCLUSION

In this study, REVUR via the extravesical approach achieved long-term success rates similar to those of OS and LS via the intravesical approach. REVUR was associated with faster postoperative recovery but incurred significantly higher costs. CUSUM analysis confirmed that the learning curve for REVUR is manageable and safe. Future prospective studies are needed to differentiate the respective contributions of robotic technique and surgical approach, and to conduct cost-effectiveness evaluations.