Harel M, Herbst K W, Silvis R, Makari J H, Ferrer F A, Kim C
University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030, USA; Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, USA.
Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, USA.
J Pediatr Urol. 2015 Apr;11(2):82.e1-8. doi: 10.1016/j.jpurol.2014.12.007. Epub 2015 Feb 26.
While open ureteral reimplantation is the gold standard of surgical intervention for vesicoureteral reflux (VUR), minimally invasive approaches offer the potential benefits of decreased postoperative pain, improved cosmesis, and shorter hospital stay and convalescence. Studies comparing open and minimally invasive surgery with respect to postoperative pain in children have been inconclusive.
We sought to compare postoperative pain in children undergoing open versus robotic ureteral reimplantation by using age-appropriate, validated pain assessment scales.
A prospective cohort of all patients enrolled in an Institutional Review Board-approved VUR surgery registry between July 2010 and February 2013 was analyzed. Patients who underwent endoscopic treatment or who received caudal or epidural anesthesia were excluded. Age-appropriate, validated pain scales ranging from 0 to 10 were utilized for pain assessment. Pain scores and narcotic doses administered on the first postoperative day were analyzed.
Of the 34 subjects included, 11 underwent open intravesical reimplantation, while 23 patients underwent robotic extravesical reimplantation. Table 1 displays patient characteristics and results of pain assessment. Robotic surgery was associated with lower narcotic requirement compared to open surgery (P < 0.05). The difference in pain scores between the two cohorts approached, but did not reach, statistical significance (P = 0.12). However, the percentage of patients with mild or no pain (57% robotic, 27% open) versus severe pain (9% robotic, 45% open) was notably different between the two cohorts.
Previous studies addressing the effect of surgical modality on pediatric postoperative pain are limited by their reliance on narcotic administration as an indirect surrogate for measuring pain. In the present study, postoperative pain was assessed with narcotic requirements and consistently collected validated pain scores, which more accurately reflect a patient's perceived pain. Although there was no significant difference in subjective pain scores between patients undergoing open versus robotic reimplantation, the percentage of patients with mild or no pain (57% robotic, 27% open) versus severe pain (9% robotic, 45% open) was notably different between the two cohorts. This study was limited by a lack of randomization as well as small sample size, which did not allow for age sub-group analysis or small differences to be statistically significant.
In the present study, robotic ureteral reimplantation was associated with lower narcotic requirement compared to open surgery, and lower intensity of postoperative pain according to a direct pain assessment tool. Larger sample sizes are necessary to strengthen statistical comparisons.
虽然开放性输尿管再植术是治疗膀胱输尿管反流（VUR）的外科干预金标准，但微创方法具有术后疼痛减轻、美容效果改善、住院时间和康复期缩短等潜在益处。关于开放性手术和微创手术对儿童术后疼痛影响的研究尚无定论。
我们试图通过使用适合年龄的、经过验证的疼痛评估量表，比较接受开放性与机器人输尿管再植术的儿童的术后疼痛情况。
对2010年7月至2013年2月期间纳入机构审查委员会批准的VUR手术登记处的所有患者进行前瞻性队列分析。排除接受内镜治疗或接受骶管或硬膜外麻醉的患者。使用范围从0到10的适合年龄的、经过验证的疼痛量表进行疼痛评估。分析术后第一天的疼痛评分和给予的麻醉剂量。
在纳入的34名受试者中，11人接受了开放性膀胱内再植术，23名患者接受了机器人膀胱外再植术。表1显示了患者特征和疼痛评估结果。与开放性手术相比，机器人手术的麻醉需求较低（P < 0.05）。两组之间的疼痛评分差异接近但未达到统计学显著性（P = 0.12）。然而，两组之间轻度或无疼痛患者的百分比（机器人手术组为57%，开放性手术组为27%）与重度疼痛患者的百分比（机器人手术组为9%，开放性手术组为45%）有显著差异。
以往关于手术方式对小儿术后疼痛影响的研究，其局限性在于依赖麻醉药物的使用作为测量疼痛的间接替代指标。在本研究中，通过麻醉需求和持续收集的经过验证的疼痛评分来评估术后疼痛，这能更准确地反映患者感知到的疼痛。虽然接受开放性与机器人再植术的患者之间主观疼痛评分没有显著差异，但两组之间轻度或无疼痛患者的百分比（机器人手术组为57%，开放性手术组为27%）与重度疼痛患者的百分比（机器人手术组为9%，开放性手术组为45%）有显著差异。本研究的局限性在于缺乏随机分组以及样本量小，这使得无法进行年龄亚组分析，也无法使小差异具有统计学显著性。
在本研究中，与开放性手术相比，机器人输尿管再植术的麻醉需求较低，并且根据直接疼痛评估工具，术后疼痛强度较低。需要更大的样本量来加强统计学比较。
