Objective pain assessment after ureteral reimplantation: comparison of open versus robotic approach.
INTRODUCTION
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.


OBJECTIVE
We sought to compare postoperative pain in children undergoing open versus robotic ureteral reimplantation by using age-appropriate, validated pain assessment scales.


METHODS
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.


RESULTS
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.


DISCUSSION
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.


CONCLUSIONS
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.