Robot Assisted Laparoscopic Partial Nephrectomy: A Viable and Safe Option in Children

A review of robotic-assisted laparoscopic partial nephrectomy in the management of renal duplication anomalies

Open and purely laparoscopic partial nephrectomy or heminephrectomy has been the standard management for renal duplication anomalies for symptomatic children with non-functional renal moieties. While robotic-assisted laparoscopic partial nephrectomy (RALPN) has been established as a safe and feasible option for the management of renal duplex anomalies, there remains a paucity of data on this topic. The aim of this study is to comprehensively review all available outcomes data and update the use of emerging technologies in robotic surgery which continue to make RALPN a viable and advantageous option in the management of renal duplex anomalies.

Robotic approach to the uretero-vesical junction in children: An international multicentric retrospective study

BACKGROUND

Robot-assisted approach to UVJ is getting more and more used in pediatric patients.

METHODS

In this retrospective study 26 patients affected by nephro-urological malformations, robotic-surgically treated from 2016 and 2021 at 3 Pediatric Surgery Department were included: 3 (11.5%) primary obstructive megaureter, 2 (7.7%) dysplastic kidneys, 3 (11.5%) duplex collecting system, 18 (69.2%) primary vescico-ureteral reflux (VUR).

RESULTS

Mean age at surgery was 6 years old. 22 (84.6%) underwent Lich Gregoire extravesical ureteral reimplantation, 4 (15.4%) total nephroureterectomy. Mean operative time was 230 min. No conversions or intraoperative complications. Median hospital stay was 4 days. There were 4 (15.38%) postoperative complications: 3 (11.54%) persistent VUR and 1 (3.84%) refluxing megaureter. 2 (7.7%) redo-surgery.

CONCLUSIONS

Robotic Surgery should be considered a safe and effective technique for treatment of UVJ anomalies in children, because it firstly allows surgeons to approach both upper and lower ureteral ends without modifying trocars' placement.

How far has robot-assisted partial nephrectomy reached?

Nephron-sparing surgery is the standard treatment for small renal mass (SRM). Nephron-sparing surgery has evolved from an open to a minimally invasive technique. Robot-assisted partial nephrectomy (RAPN) is the latest technique in this field and is reported to be safe and feasible, showing oncologically and functionally superior or compatible results compared with open and laparoscopic partial nephrectomy for SRM. This is not limited to only SRM but also applies to large and complex renal masses and other challenging situations. RAPN showed good oncological and functional outcomes for ≥clinical T2 renal tumors, complex renal masses (PADUA score ≥10, RENAL score ≥10), hilar renal tumors, and multiple renal tumors. In addition, the outcomes of RAPN in these challenging cases were not inferior to those in conventional cases. RAPN could also be applied to a number of challenging cases in which the open technique was considered first. RAPN showed good results in patients with a solitary kidney, horseshoe kidney, and in repeat surgeries. Furthermore, RAPN could be safely performed on obese, elderly, and pediatric patients. Finally, this review evaluates efficiency and utility of RAPN based on the results of challenging cases of renal masses and to project the future of RAPN.

Robotic-Assisted Minimally Invasive Surgery in Children

Currently, minimally invasive surgery (MIS) includes conventional laparo-thoracoscopic surgery and robot-assisted surgery (RAS) or robotic surgery. Robotic surgery is performed with robotic devices, for example the Da Vinci system from Intuitive Surgical, which has a miniaturized camera capable of image magnification, a three-dimensional image of the surgical field, and the instruments are articulated with 7 degrees of freedom of movement, and the surgeon operates in a sitting position at a surgical console near the patient. Robotic surgery has gained an enormous surge in use on adults, but it has been slowly accepted for children, although it offers important advantages in complex surgeries. The areas of application of robotic surgery in the pediatric population include urological, general surgery, thoracic, oncological, and otorhinolaryngology, the largest application has been in urological surgery. There is evidence that robotic surgery in children is safe and it is important to offer its benefits. Intraoperative complications are rare, and the frequency of postoperative complications ranges from 0–15%. Recommendations for the implementation of a pediatric robotic surgery program are included. The future will be fascinating with upcoming advancements in robotic surgical systems, the use of artificial intelligence, and digital surgery.

Artificial Intelligence and Its Impact on Urological Diseases and Management: A Comprehensive Review of the Literature

Recent advances in artificial intelligence (AI) have certainly had a significant impact on the healthcare industry. In urology, AI has been widely adopted to deal with numerous disorders, irrespective of their severity, extending from conditions such as benign prostate hyperplasia to critical illnesses such as urothelial and prostate cancer. In this article, we aim to discuss how algorithms and techniques of artificial intelligence are equipped in the field of urology to detect, treat, and estimate the outcomes of urological diseases. Furthermore, we explain the advantages that come from using AI over any existing traditional methods.

Robotics in Pediatric Urology: Evolution and the Future

Almost 30 years have passed since the inception of minimally invasive surgery in urology and specifically in pediatric urology. Laparoscopy has now become an essential tool in the pediatric urologic armamentarium. The application of robot-assisted surgery in pediatrics has allowed for widespread utilization for common reconstructive procedures such as pyeloplasty and ureteral reimplantation. Understanding the implementation, technical considerations, and outcomes are critical for continued success and adoption. This has allowed for increased use in more complex urologic procedures such as redo pyeloplasty, dismembered ureteral reimplantation, catheterizable channel creation, and bladder augmentation.

Long-Term Follow-Up of Laparoendoscopic Single-Site Partial Nephrectomy for Nonfunctioning Moieties of Renal Duplication and Fusion Anomalies in Infants and Children

Objectives: To report on long-term follow-up and outcomes of infants and small children who have undergone laparoendoscopic single-site (LESS) partial nephrectomy to manage upper urinary tract duplication and fusion anomalies. Materials and Methods: A retrospective review was performed evaluating outcomes of pediatric patients who underwent LESS partial nephrectomy for upper urinary tract duplication and fusion anomalies from January 2012 to July 2015, by a single surgeon at a tertiary pediatric referral center. Demographic and perioperative data were reviewed as well as follow-up imaging. Descriptive statistics were used for analysis. Results: A total of 18 patients were identified. Additional access was used for two patients to complete the procedure. Median follow-up was 39 months. No short-term complications were encountered. Three patients were noted to have abnormal postoperative ultrasounds: two perinephric fluid collections and one atrophy of the remaining ipsilateral moiety. One fluid collection resolved completely, and the other decreased in size. Complete atrophy of the ipsilateral moiety occurred. No secondary procedures were required. Conclusions: LESS partial nephrectomy is safe for renal duplication and fusion anomalies with good long-term outcomes. Although it can be safely performed, it is a technically demanding procedure and has been discontinued in favor of robotic partial nephrectomy.

Laparoscopic Heminephrectomy for Duplex Kidney in Children-The Learning Curve

Objectives: Outcomes evolution during the learning curve of laparoscopic transperitoneal heminephrectomy in children with a duplex kidney. Materials and Methods: The data of 33 children, operated on between 2008 and 2017, with complicated duplex kidney, were subjected to a retrospective analysis. All patients were operated on by transperitoneal access using the laparoscopic technique. Patients were divided into two groups (1: subsequent operation 1-16, and 2: operations 17-33) to evaluate the learning curve. Results: There was no need for conversion. Total complications occurred in seven patients in Group 1 and 2 patients of Group 2 (p < 0.05). Two patients (6%) (both upper pole heminephrectomies) required reoperation to remove the ureter stump because of recurrent UTIs due to undiagnosed VUR to the stump (1 from each of Groups 1 and 2). Prolonged urine leakage (over 4 days) was observed in four patients (12%; all from group 1); in three patients, conservative treatment was successful, while the placement of a DJ catheter was needed in the fourth. A significant decrease of kidney function (>6%) in scintigraphy was observed in two of the 15 patients after the surgery. The time of surgery decreased from 140 (range 85-185) min in Group 1 to 125 (range 100-150) min in Group 2 (p < 0.05). Conclusions: Laparoscopic heminephrectomy is connected to the learning curve. Most complications occurred in the first 16 operations. With increasing experience, the time of operation decreased. In patients with reflux to the upper pole, referred for upper pole heminephrectomy, it is necessary to consider the removal of the ureter to the level of the vesicoureteral junction.

A contemporary single-institution retrospective cohort study comparing perioperative outcomes between robotic and open partial nephrectomy for poorly functioning renal moieties in children with duplex collecting systems

INTRODUCTION

Studies evaluating robotic-assisted laparoscopic partial nephrectomy (RALPN) are limited to case series, amounting to a lack of studies directly comparing perioperative outcomes for RALPN to open partial nephrectomy (OPN).

OBJECTIVE

To compare perioperative outcomes between RALPN and OPN.

METHODS

A single-institution, retrospective cohort study was performed to compare perioperative outcomes (operative time (OT), length of stay (LOS), complications, readmissions, postoperative interventions, loss in size of the residual moiety, and the presence of postoperative 'contained fluid collections') for RALPN and OPN between February 2007 and July 2014. Descriptive statistics were calculated and unadjusted analyses performed, including Chi-squared/Fisher's exact for categorical variables and Wilcoxon rank sum for continuous variables.

RESULTS

During the study period, 43 partial nephrectomies were performed for benign disease: 27 (63%) RALPN and 16 (37%) OPN. The RALPN cohort was significantly older than the OPN cohort (3.5 vs. 0.8 years; P = 0.003). The cohorts were otherwise similar regarding race, American Society of Anesthesiologist score (ASA), affected moiety, laterality, associated anomalies, moiety function, and surgical indication. Robotic-assisted laparoscopic partial nephrectomy was associated with a significantly shorter LOS (1 vs. 3 days; P = 0.002). Operative time and complication rates were comparable. The OPN group had a longer median follow-up (2.7 years vs. 1.1; P = 0.03). No differences were observed between the cohorts for readmissions, postoperative interventions, loss in size of residual moiety, or development of 'contained fluid collections'. These outcomes are reported in the Summary Table. 'Contained fluid collections' occurred more frequently after lower pole resections (73% vs. 30%; P = 0.009).

DISCUSSION

This study is one of the few to directly compare RALPN to OPN, and demonstrated that RALPN has comparable (if not better) outcomes than OPN. In particular, RALPN provides the advantage of a shorter LOS. Avoiding the flank incision used in OPN may also offer reduced pain; however, this was not studied here and the literature provides weak evidence for this effect. This unadjusted analysis may have been confounded by its short median follow-up and significantly younger OPN cohort.

CONCLUSION

In this contemporary comparative analysis, RALPN predicted a similar median OT and safety profile to OPN while offering the advantage of a shorter LOS. Regardless of surgical cohort, there were no adverse effects on the residual renal moieties and postoperative 'contained fluid collections' occurred with notable frequency and were independently associated with lower pole pathology.

Partial nephrectomy for small children: Robot-assisted versus open surgery

OBJECTIVES

To compare the outcomes of robot-assisted heminephrectomy for duplex kidney in children with those of open heminephrectomy.

METHODS

The present retrospective multicentric analysis reviewed the records of robot-assisted versus open heminephrectomy carried out for duplex kidney in children from 2007 to 2014. Demographic data, weight, surgical time, hospital stay, complications and outcome were recorded. Follow up was based on a clinical review, renal sonography and dimercaptosuccinic acid renal scintigraphy.

RESULTS

A total of 15 patients underwent robot-assisted heminephrectomy, and 13 patients underwent retroperitoneal heminephrectomy by open approach. All patients weighed <15 kg. The mean age at the time of surgery was 20.2 months (range 7-39 months) in the robotic group, and 18.4 months (range 6-41 months) in the open group. The mean hospital stay was statistically longer for the open surgery group (6.3 days, range 5-8 days vs 3.4 days, range 1-7 days; P < 0.001). Regarding postoperative pain control, total morphine equivalent intake was statistically greater for the open group (0.52 mg/kg/day vs 1.08 mg/kg/day; P < 0.001). No patient lost the remaining healthy moiety. There was no significant difference in terms of operating time, complication rate or renal outcomes.

CONCLUSIONS

Robot-assisted heminephrectomy in small children seems to offer comparable renal outcomes with those of its standard open surgery counterpart. Specific technical adjustments are necessary, which typically increase the set-up time.

Robot-assisted laparoscopic extravesical ureteral reimplant: A critical look at surgical outcomes

BACKGROUND

Published reports of outcomes of robot assisted laparoscopic ureteral reimplantation (RALUR) show mixed results that, on average, are inferior to open ureteral reimplant. We present a retrospective analysis of a prospective series of children who had RALUR from 2013 to June 2015. We hypothesized that surgical outcomes are based on identifiable risk variables. We provide a critical analysis of the relationship between patient characteristics and several surgical and non-surgical outcomes.

METHODS

We reviewed the records of children who had Robot-Assisted Laparoscopic (RAL) Ureteral Reimplant (UR) at Nationwide Children's Hospital. Patient age and gender, preoperative presentation, presence of preoperative bladder and bowel dysfunction (BBD), VUR grade and laterality, indication for operation, operative time, surgical outcome, surgical complications, post-operative prevalence of UTI, and pre- and post-operative status of BBD were recorded. We also recorded techniques for ureteral dissection, and closing the detrusorrhaphy. Surgical outcome was defined by post-operative VCUG. We define BBD based on publications by the standardization committee of International Children's Continence Society (ICCS). All statistical calculations were performed with STATA version 11.

RESULTS

We performed extravesical RALUR on 54 children for a total of 72 ureters. Overall the study children were 74% female. The mean and median age was 5.2 and 4.9 years, respectively. Mean overall hospital length of stay (LOS) was 1.64 days. The mean LOS was 1.26 for unilateral (RALUUR) and 2.39 days for bilateral (RALBUR) surgeries and was significant (p < 0.05). Overall surgical success was 85.2% of ureters and 84.7% of children. Stratified by unilateral and bilateral surgeries, unilateral success was 91.7%, and bilateral success was 77.8% of ureters, and 72.2% of children. In the 3 failures in the RALUUR group the mean postoperative VUR grade was 1.3 from a pre-op mean grade of 3.3, whereas in the RALBUR group, the mean VUR grade among the failures was 3.0 from a mean pre-op VUR grade of 3.7. Urinary leak from ureteral injury, and urinary obstruction were more common in the RALBUR group. Post-operative urinary retention occurred in 4 children in the RALBUR and none in the RALUUR groups. Four with VUR after RALBUR and one child after RALUUR had open ureteral reimplant. Post-op UTI and non-surgical readmissions were higher in the RALBUR group.

CONCLUSIONS

Bilateral RALUR is associated with higher failure rates, higher complication rates, higher re-operation rates, and more postoperative UTIs and nonsurgical readmissions compared with unilaterasl RALUR.

Robot-assisted laparoscopic lower pole partial nephrectomy in the pediatric patient

INTRODUCTION

In pediatric urology, partial nephrectomy is used primarily to remove a non-functioning renal moiety in a duplicated system. There are few data on infants undergoing this procedure. As such, we present a robot-assisted laparoscopic lower pole partial nephrectomy in an infant.

METHODS

Our patient was an 11-month-old (10.7 kg) male with a history of prenatal hydronephrosis, who was diagnosed postnatally with a duplicated right collecting system and severe hydroureteronephrosis of the right lower collecting system. A DMSA scan demonstrated no radiotracer uptake in the right lower pole. A robot-assisted laparoscopic lower pole partial nephrectomy was performed.

RESULTS

A lower pole partial nephrectomy was accomplished. At 1 month postoperatively, an ultrasound demonstrated no hydronephrosis or perinephric fluid collection.

CONCLUSIONS

Robotic partial nephrectomy is safe and feasible in pediatrics including both older children and infants. It is successful for both upper and lower pole partial nephrectomies.

What's the best minimal invasive approach to pediatric nephrectomy and heminephrectomy: conventional laparoscopy (CL), single-site (LESS) or robotics (RAS)?

BACKGROUND

Conventional laparoscopy (CL) using 3-5 mm ports has become the goldstandard for pediatric nephrectomy (N), heminephrectomy (HN) and heminephrecto-ureterectomy (HNU) for many years now. Recently the spectrum of minimal invasive surgery (MIS) has been extended by variants like laparoendoscopic single-site surgery (LESS) or robot-assisted surgery (RAS). However such technical developments tend to drive surgical euphoria and feasibility studies, but may miss adequate academic research about function and proven patients' benefits. This article delivers a comprehensive analysis of present pediatric studies comparing at least two MIS approaches to N, HN and HNU.

METHODS

A systematic literature-based search for studies published between 2011-2016 about CL versus LESS or RAS for pediatric N, HN, and HNU was performed using multiple electronic databases and sources. The level of evidence was determined using the Oxford Centre for Evidence-based Medicine (OCEBM) criteria. Single arm observational studies about N, HN or HNU using CL, LESS or RAS as well as publications including adult patients were excluded.

RESULTS

A total of 11 studies met defined inclusion criteria, reporting on CL versus LESS or RAS. No studies of OCEBM Level 1 or 2 were identified. Performing CL for N and HN limited evidence indicated reduced analgesic requirements and shorter hospital stay over open surgery, but longer operating time. Preservation of renal function of the remaining moiety after CL-HN was 95%. Importantly, of patients losing their remaining moiety, median age at surgery was 9 months (range, 4-42 months), and all except 1 (6/7) had an upper pole HN. Several authors compared TNP versus RPN access for CL and confirmed a longer operating time for RPN versus TPN-NU. Moreover one study reported a longer ureteric stump in RPN versus TPN-HNU (range, 2-5 cm vs. 3-7 mm). Disadvantages of LESS or RAS over CL were longer operative time and higher total costs (RAS). There were no differences regarding complications, success rates, or short-term outcomes between pediatric RAS versus CL. No long-term studies about preservation of renal function or length of ureteric stump using LESS or RAS could be retrieved.

CONCLUSIONS

Several approaches to MIS-NU and HNU are available today. CL represents the method of choice for any age group. TPN or RPN can be chosen according to age of the patient. LESS and RAS offer distinct advantages, but also lack evident patients' benefits over CL at present. Hopefully, as pediatric MIS advances over the next decade, larger studies comparing CL, LESS or RAS directly for pediatric NU and HNU will be published to gain a higher level of evidence what's really best for the child.

Robotic surgery in pediatric urology

While robotic surgery has shown clear utility and advantages in the adult population, its role in pediatrics remains controversial. Pediatric-sized robotic instruments and equipment are not readily available yet, so certain modifications can be made in order to make robotic surgery successful in children. While the cost of robotic surgery remains high compared to open procedures, patients experience greater satisfaction and quality of life with robotic surgery. Robotic pyeloplasty is a standard of care in older children, and has even been performed in infants and re-do surgery. Other robotic procedures performed in children include heminephroureterectomy, ureteroureterostomy, ureteral reimplantation, urachal cyst excision, bladder diverticulectomy, and bladder reconstructive procedures such as augmentation, appendicovesicostomy, antegrade continence enema, bladder neck reconstruction and sling, as well as other procedures. Robotic surgery has also been used in oncologic cases such as partial nephrectomy and retroperitoneal lymph node dissection. Future improvements in technology with production of pediatric-sized robotic instruments, along with increases in robotic-trained pediatric urologists and surgeon experience along each's learning curve, will help to further advance the field of robotic surgery in pediatric urology.

Robot-assisted laparoscopic management of duplex renal anomaly: Comparison of surgical outcomes to traditional pure laparoscopic and open surgery

INTRODUCTION

Surgical management of duplex renal anomaly (DRA) is complex because of individual anatomic variation, competing priorities of vesicoureteral reflux (VUR) and ureteral obstruction present in the same child, the varied differential function of the different renal moieties, and the presence of voiding dysfunction and recurrent urinary tract infection (UTI). Robot-assisted laparoscopic (RAL) surgical management has been under-reported in this group of children but is becoming a viable alternative to traditional open surgery.

OBJECTIVE

The aim was to report the surgical outcomes of a series of children with DRA who had RAL surgery and compare these outcomes to historical cohorts of open and laparoscopic surgery.

STUDY DESIGN

This was a retrospective analysis of a prospective series of children who had RAL surgery for DRA over an 8-year period. Forty-five RAL surgeries were performed in 47 children. RAL heminephrectomy (RAL HN) was performed in 19 children for poorly or non-functional renal moiety. One had staged bilateral RAL HN. RAL ureteroureterostomy (RAL UU) was performed in 14 children for upper pole ureteral obstruction. Thirteen RAL common sheath ureteral reimplants (RAL csUN) with or without ureteral tapering were performed in 12 children with VUR and UTI. Diagnosis and demographics, results of preoperative imaging, intraoperative time stamps, perioperative complications, success rate, and renal outcomes were recorded.

RESULTS

Low-grade VUR present preoperatively in the RAL UU group all resolved within the follow-up period. Four (25%) children in the RAL HN group developed de novo VUR after surgery, which resolved in two (50%) and required surgery in two (50%). Grade I VUR after RAL csUR that occurred in two (14.3%) children was asymptomatic and observed when off preventative antibiotics.

DISCUSSION

Most children with DRA who need surgical treatment can be offered RAL surgery. We report good outcomes and improved operative times for RAL HN and UU that approach historical open and pure laparoscopic cohorts. However, RAL csUR, especially with ureteral tapering, is more complex and inherently susceptible to complications, and has not met the outcomes of the open gold standard. The limits of this study are that selection bias is present, and there is no study control cohort.

CONCLUSIONS

This report achieves its aim to report surgical outcomes of children who had RAL surgery for DRA.

Simultaneous bilateral robotic-assisted laparoscopic procedures in children

Our main objective is to report the feasibility of performing simultaneous robotic-assisted laparoscopic (RAL) heminephrectomy with contralateral ureteroureterostomy in children with bilateral duplicated systems. Three female children with bilateral congenital renal/ureteral anomalies underwent concurrent RAL simultaneous unilateral partial nephrectomy with ureterectomy and contralateral ureteroureterostomy with redundant ureterectomy using a four/five-port approach. Mean age at repair was 32.9 months (range 7-46 months) and mean weight was 13.7 kg (range 10.4-13.6 kg). The RAL heminephroureterectomy and contralateral ureteroureterostomy were performed via a four-port approach (five ports in one patient), and the patients were repositioned and draped when moving to the other side. Mean operative time was 446 min (range 356-503 min). Mean estimated blood loss was 23.3 cc (range 10-50 cc). Postoperative length of stay for two patients was 2 days and 1 day for one patient (mean = 1.7 days). Mean length of follow-up was 18.3 months (range 7-36 months). No significant intraoperative or postoperative complications occurred for any of the three patients. Two children had no hydronephrosis on postoperative imaging in follow-up, and one child had a small stable, residual pararenal fluid collection on the side of heminephrectomy. Two patients underwent postoperative ureteral stent removal under general anesthesia. In children with bilateral duplicated urinary tract with ureterocele, ectopic ureter, and/or vesicoureteral reflux, laparoscopic repair with robotic assistance can be accomplished safely in a single operative procedure with a short hospital stay.

Outcomes in Pediatric Robot-Assisted Laparoscopic Heminephrectomy Compared with Contemporary Open and Laparoscopic Series

PURPOSE

To compare our renal and clinical outcomes for robot-assisted laparoscopic heminephrectomy (RAL-HN) in the pediatric population with duplicated systems with those of current contemporary open and laparoscopic series.

PATIENTS AND METHODS

Sixteen children underwent RAL-HN from 2009 to 2014. Data were collected via retrospective chart review including demographics, preoperative and postoperative imaging, operative time, estimated blood loss (EBL), length of stay (LOS), complications, and renal outcomes.

RESULTS

Mean age at surgery was 37.5±49.2 months. Mean operative time was 135±36 minutes with an EBL of 10±5 mL. Mean LOS was 2±0.8 days, and no major perioperative complications were observed. Mean follow-up was 22.1±17.2 months. Two patients needed secondary ureterectomy for recurrent urinary tract infection in the setting of a refluxing ureteral stump. One of these patients also underwent a ureteral reimplantation of the ipsilateral normal ureter. No patients lost their remaining healthy moiety. Asymptomatic cyst formation was seen in four (25%) patients, and self- limited postoperative urinoma was seen in 2 (13%) patients. Postoperative perinephric abscess did not develop in any patient. Mean change in renal function based on nuclear renography of the duplex kidney was -2.7%±4.6%.

CONCLUSIONS

Compared with previously published literature evaluating open and laparoscopic heminephrectomy, RAL-HN provides comparable outcomes in regard to complication rate and renal function of the remnant moiety.

How small is small enough? Role of robotics in paediatric urology

The well-known advantages of robotic surgery include improved dexterity, three-dimensional operating view and an improved degree of freedom. Robotic surgery is performed for a wide range of surgeries in urology, which include radical prostatectomy, radical cystectomy, and ureteric reimplantation. Robotic paediatric urology is evolving. The major hindrance in the development of paediatric robotics is, first, the differences in practice patterns in paediatric urology compared with adult urology thereby making development of expertise difficult and secondly it is challenging to conduct proper studies in the paediatric population because of the paucity of cases. The difficulties in conducting these studies include difficulty in designing a proper randomised study, difficulties with blinding, and finally, the ethical issues involved, finally the instruments although in the phase of evolution require a lot of improvement. In this article, we review the relevant articles for paediatric robotic surgery. We emphasise on the technical aspects and results in contemporary paediatric robotic case series.

Robotic appendicovesicostomy revision in children: description of technique and initial results

PURPOSE

To report our initial results of robotic appendicovesicostomy (APV) revision in children.

PATIENTS AND METHODS

Three patients (median age 6 years; range 6-13) underwent robot-assisted APV surgery for bladder dysfunction because of posterior urethral valves, myelomeningocele, and traumatic spinal cord transection. Leakage developed in each patient from the APV. After failing more conservative treatments, the patients subsequently underwent robot-assisted APV revision.

RESULTS

Robot-assisted APV revision was conducted at a median 14 months (range 6-34 mos) after initial surgery. Median operative time was 165 minutes (range 106-232 min), and blood loss was ≤5 mL for all patients. Intraoperative findings ranged from partial to complete separation of the APV from the bladder tunnel. APV leakage resolved for all patients at last follow-up (median 5 months; range 2-9 mos).

CONCLUSION

This initial series expands the scope of robotic surgical procedures in children. Robot-assisted APV revision was technically feasible and safe in this early experience.

[Laparoscopic robot-assisted partial nephrectomy with total ureterectomy in a symptomatic complete duplicated system: advantages of transperitoneal approach]

We report the case of a laparoscopic robot assisted left upper polar partial nephrectomy with total ureterectomy performed in a teenager. A 14 year-old girl was referred to our institution for stress urinary incontinence. The morphological assessment (ultrasound scan and uro-MRI) showed a double collecting system with a complete ureteral duplication complicated by a dysplasia of the upper moiety of the duplex left kidney and a mega ureter. The surgery started on a lateral decubitus position by the upper polar partial nephrectomy and the ureter section behind superior polar renal vessels. The patient was placed in a supine position and the mega ureter was released and sectioned at the level of the distal adynamic segment in the left uterine parameter. The transperitoneal route was chosen as it provides a large workspace and allows the dissection of the ureters into their pelvic portion by a simple repositioning of the robot ports without additional incision and without any modification of the operative field. No intraoperative and postoperative complication was noticed. Laparoscopic robotic assisted surgery in pediatric urology is increasing, and to our knowledge, we reported this technique and surgery for the first time in France and in children. In the reported case, we showed that the robotic minimally invasive surgery in children is an innovative and safe technique for the treatment of symptomatic upper urinary tract malformations.

Current status of robot-assisted laparoscopic surgery in pediatric urology

Laparoscopic procedures for urological diseases in children have been proven to be safe and effective. However, the availability of laparoscopic procedures is still partly limited to experienced, high-volume centers because the procedures are technically demanding. The da Vinci robot system is being used for an increasing variety of reconstructive procedures because of the advantages of this approach, such as motion scaling, greater optical magnification, stereoscopic vision, increased instrument tip dexterity, and tremor filtration. Particularly in pediatric urologic surgery, where the operational field is limited owing to the small abdominal cavity of children, robotic surgical technology has its own strengths. Currently, robots are used to perform most surgeries in children that can be performed laparoscopically. In this review, we aimed to provide a comprehensive overview of the current role of robot-assisted laparoscopic surgery in Pediatric Urology by analyzing the published data in this field. A growing body of evidence supports the view that robotic technology is technically feasible and safe in pediatric urological surgery. Robotic technology provides additional benefits for performing reconstructive urologic surgery, such as in pyeloplasty, ureteral reimplantation, and enterocystoplasty procedures. The main limitations to robotic surgery are its high purchase and maintenance costs and that the cost-effectiveness of this technology remains to be validated.

Infant robotic bilateral upper urinary tract surgery

We describe a case of robot-assisted laparoscopic bilateral upper urinary tract surgery in a 4-month-old infant for complex bilateral upper urinary tract duplication anomalies.

Infant robotic pyeloplasty: comparison with an open cohort

OBJECTIVE

To present our experience with infant pyeloplasty, comparing outcomes between robotic-assisted laparoscopic pyeloplasty (RALP) and open pyeloplasty (OP).

MATERIALS AND METHODS

A retrospective review was performed of all children <1 year of age who underwent unilateral dismembered pyeloplasty at a single pediatric institution since January 2007. Patients with standard laparoscopic pyeloplasty were excluded. Patient demographics, intraoperative details, narcotic usage, and complications were reviewed.

RESULTS

A total of 70 infants (51 boys and 19 girls) were identified, with nine RALP and 61 OP performed. Median age was 9.2 months (range, 3.7-11.9 months) for RALP and 4.1 months (range, 1.0-11.6 months) for OP (p = 0.005). Median weight was 8 kg (range, 5.8-10.9 kg) for RALP and 7 kg (range, 4-14 kg) for OP (p = 0.163). Median operative time was 115 min (range, 95-205 min) for RALP and 166 min (range, 79-300 min) for OP (p = 0.028). Median hospital stay was 1 day (range, 1-2 days) for RALP and 3 days (range, 1-7 days) for OP (p < 0.001). Median postoperative narcotic use of morphine equivalent was <0.01 mg/kg/day (range, 0-0.1 mg/kg/day) for RALP and 0.05 mg/kg/day (range, 0-2.2 mg/kg/day) for OP (p < 0.001). Median follow-up was 10 months (range, 7.2-17.8 months) for RALP and 43.6 months (3.4-73.8 months) for OP (p < 0.001). The success rate was 100% for RALP and 98% for OP.

CONCLUSIONS

Infant RALP was observed to be feasible and efficacious with shorter operative time, hospital stay, and narcotic utilization than OP.

Robotic-assisted partial nephrectomy in duplicated collecting systems in the pediatric population: techniques and outcomes

OBJECTIVE

We present our experience with pediatric robotic-assisted laparoscopic partial nephrectomy of a nonfunctioning moiety in a duplicated system (RALPN), comparing techniques and outcomes with those previously reported in the literature. To our knowledge, this is the largest series of this surgical procedure to date.

PATIENTS AND METHODS

We retrospectively reviewed all pediatric patients at our institution that had undergone RALPN from 2006 to 2012.

RESULTS

Twenty-one patients underwent RALPN between 2006 and 2012. Mean patient age was 4.1 years. Mean operative time was 301 min. Mean estimated blood loss was 36 ml. Mean length of stay was 38 h. The majority of cases were performed with three laparoscopic ports. At initial follow-up ultrasound 6/21 (29%) demonstrated a fluid collection. The majority of these collections occurred in cases where the resection defect was not closed intraoperatively (42% of cases vs. 11% of cases). All fluid collections were asymptomatic and managed conservatively.

CONCLUSION

RALPN is associated with low complication rates. The robotic system allows for the use of only two small robotic working ports in most cases. Postoperative fluid collections may be prevented by formal closure of the polar defect, but fluid collections that do occur can be followed conservatively.

The feasibility of robotic urologic surgery in infants and toddlers

OBJECTIVE

To determine the feasibility and safety of performing robotic-assisted laparoscopic urological surgery (RALS) in infants and young children, highlighting technical challenges posed by the smaller body size and their potential solutions.

PATIENTS AND METHODS

We retrospectively reviewed perioperative records of all patients less than 3 years of age who underwent RALS at our institution between January 2006 and October 2012. Intraoperative data included difficulties with the robotic instruments or surgical procedure. Post-operative data included length of hospital stay and any complications.

RESULTS

A total of 65 children less than 3 years underwent RALS. The average patient age was 1.6 years ± 0.7, with 14 patients under 1 year of age. Median patient weight was 11.6 kg ± 2.5 kg. Mean operative time was 153.3 ± 57 min. No conversions to open technique or intra-operative complications were reported. A total of 12 post-operative complications were identified after a mean follow-up of 13.6 months: 7 early complications and 5 late complications. Smaller children did not have more complications than larger children.

CONCLUSION

There are inherent challenges with performing RALS in infants and young children. However, they may be overcome with specific technical maneuvers and through understanding of the limitations of the robotic system.

Current controversies in pediatric urologic robotic surgery

PURPOSE OF REVIEW

Minimally invasive surgeries such as conventional laparoscopic surgery and robotic assisted laparoscopic surgery (RALS) have significant advantages over the traditional open surgical approach including lower pain medication requirements and decreased length of hospitalization. However, open surgery has demonstrated better success rates and shorter surgery time when compared to the other modalities. Currently, it is unclear which approach has better long-term clinical outcomes, greater benefits and less cost.

RECENT FINDINGS

There are limited studies in the literature comparing these three different surgical approaches. In this review, we will evaluate the advantages and disadvantages of RALS compared to conventional laparoscopic surgery and open surgery for commonly performed pediatric urological procedures such as pyeloplasty, ureteral reimplantation, complete and partial nephrectomy, bladder augmentation and creation of continent catheterizable channels.

SUMMARY

Although it is not yet possible to demonstrate the superiority of one single surgical modality over another, RALS has been shown to be feasible, well tolerated and advantageous in reconstructive urological procedures. With experience, the outcomes of RALS are improving, justifying its usage. However, cost remains a significant issue, limiting the accessibility of RALS, which in the future may improve with market competition and device innovation.

Robotic versus laparoscopic partial nephrectomy: a systematic review and meta-analysis

CONTEXT

Centres worldwide have been performing partial nephrectomies laparoscopically for greater than a decade. With the increasing use of robotics, many centres have reported their early experiences using it for nephron-sparing surgery.

OBJECTIVE

To review published literature comparing robotic partial nephrectomy (RPN) with laparoscopic partial nephrectomy (LPN).

EVIDENCE ACQUISITION

An online systematic review of the literature according to Cochrane guidelines was conducted from 2000 to 2012 including studies comparing RPN and LPN. All studies comparing RPN with LPN were included. The outcome measures were the patient demographics, tumour size, operating time, warm ischaemic time, blood loss, transfusion rates, length of hospital stay, conversion rates, and complications. A meta-analysis of the results was conducted. For continuous data, a Mantel-Haenszel chi-square test was used; for dichotomous data, an inverse variance was used. Each was expressed as a risk ratio with a 95% confidence interval p<0.05 considered significant.

EVIDENCE SYNTHESIS

A total of 717 patients were included, 313 patients in the robotic group and 404 patients in the laparoscopic group (seven studies). There was no significant difference between the two groups in any of the demographic parameters except for age (age: p=0.006; sex: p=0.54; laterality: p=0.05; tumour size: p=0.62, tumour location: p=57; or confirmed malignant final pathology: p=0.79). There was no difference between the two groups regarding operative times (p=0.58), estimated blood loss (p=0.76), or conversion rates (p=0.84). The RPN group had significantly less warm ischaemic time than the LPN group (p=0.0008). There was no difference regarding postoperative length of hospital stay (p=0.37), complications (p=0.86), or positive margins (p=0.93).

CONCLUSIONS

In early experience, RPN appears to be a feasible and safe alternative to its laparoscopic counterpart with decreased warm ischaemia times noted.

Robotic paediatric urology

What's known on the subject? and What does the study add? Robot assisted laparoscopic surgery (RALS) is slowly gaining acceptance in the field of paediatric urology. Accumulating data on safety and efficacy when performing paediatric robotic urologic procedures has led paediatric urologists to gradually embrace increasingly more complex reconstructive surgeries. Indeed, the unique and delicate movements generated by the robotic system make this technology ideal for children who often require reconstructive procedures. We critically review the current role of RALS in paediatric urology and to analyse the published data, with a special emphasis on the most common applications. We also propose a structured plan to expedite training and the surgical 'learning curve'.

OBJECTIVES

To critically review the current role of robot-assisted laparoscopic surgery (RALS) in paediatric urology and to analyse the published data, with a special emphasis on the most common applications. One of the greatest benefits of RALS has been the ability to truly spread the application of minimally invasive surgery to paediatric surgical patients. The unique attributes of the robotic interface make this technology ideal for children with congenital anomalies, who often require reconstructive procedures. We also propose a structured plan to expedite training and the surgical 'learning curve'.

PATIENTS AND METHODS

Currently, almost all urological surgical procedures in children have been performed with the assistance of the robotic interface. The most commonly performed procedures include pyeloplasty, nephrectomy/hemi-nephrectomy and surgery for vesico-ureteric reflux. Initial series of bladder augmentation and appendicovesicostomy are available.

RESULTS

Initial results with RALS are encouraging and have shown safety similar to open procedures, and outcomes at least equivalent to standard laparoscopy. Accumulating data have consistently shown that postoperative analgesia requirements and overall hospital stay are decreased. However, operative durations are significantly longer than their open counterparts, but this is decreasing as experience accumulates.

CONCLUSIONS

RALS is already part of paediatric urological surgery. Larger single-institution case series and comparative studies with the open approach and multi-institutional meta-analyses will help to identify the benefits of RALS in paediatric urology.

Pediatric laparoscopic and robot-assisted laparoscopic surgery: technical considerations

Laparoscopy has become an effective modality for the treatment of many pediatric urologic conditions that need both extirpative and reconstructive techniques. Laparoscopic procedures for urologic diseases in children, such as pyeloplasty, orchiopexy, nephrectomy, and bladder augmentation, have proven to be safe and effective with outcomes comparable to those of open techniques. Given the steep learning curve and technical difficulty of laparoscopic surgery, robot-assisted laparoscopic surgery (RAS) is increasingly being adopted in pediatric patients worldwide. Anything that can be performed laparoscopically in adults can be extended into pediatric practice with minor technical refinements. We review the role of laparoscopic and RAS in pediatric urology and provide technical considerations necessary to perform minimally invasive surgery successfully.

Is robotic technology facilitating the minimally invasive approach to partial nephrectomy?

OBJECTIVE

• To establish its current status, this study reviews the literature, and reports developments in robotic-assisted partial nephrectomy (RPN), highlighting results from various studies that investigate the oncological and functional efficacy of RPN. Partial nephrectomy has become the standard therapy for the management of small renal masses. In an effort to overcome the perioperative morbidity associated with an open approach, and the extended warm ischaemia times associated with a laparoscopic approach, robotic platforms have been introduced.

PATIENTS AND METHODS

• A search of Medline, EMBASE and Cochrane library databases was completed in July 2010 and used to identify pertinent original articles, editorials, comments and reviews, using the search term 'partial nephrectomy'. Links to related references were surveyed, and all articles finally included were based on relevance and importance of content, as determined by the authors.

RESULTS

• The robotic platform may offer the solution to bridge the gap between open and laparoscopic approaches, achieving warm ischaemia times that consistently average 20 minutes, and providing similar oncological and functional results via a shorter learning curve. It offers cosmesis and convalescence equivalent to that from laparoscopic partial nephrectomy, but with potentially fewer postoperative complications.

CONCLUSION

• In terms of oncological and functional outcomes, the early experiences of RPN in selected series of patients appear at least equivalent to open and laparoscopic partial nephrectomy series. Randomized comparisons between the approaches are lacking, as are longer-term follow-up data for the robotic technique and formal cost analysis; these will be necessary before RPN can replace open partial nephrectomy as the new standard for the management of small renal masses. Trends continue to emerge that highlight the advantage of using the robotic platform to achieve a minimally invasive approach for partial nephrectomy, and with time and increasing expertise, this may become further apparent.

Robot-assisted laparoscopic partial nephrectomy: Current review of the technique and literature

AIM:

To visit the operative technique and to review the current published English literature on the technique, and outcomes following robot-assisted laparoscopic partial nephrectomy (RPN).

MATERIALS AND METHODS:

We searched the published English literature and the PubMed^(™) for published series of ‘robotic partial nephrectomy’ (RPN) using the keywords; robot, robot-assisted laparoscopic partial nephrectomy, laparoscopic partial nephrectomy, partial nephrectomy and laparoscopic surgery.

RESULTS:

The search yielded 15 major selected series of ‘robotic partial nephrectomy’; these were reviewed, tracked and analysed in order to determine the current status and role of RPN in the management of early renal neoplasm(s), as a minimally invasive surgical alternative to open partial nephrectomy. A review of the initial peri-operative outcome of the 350 cases of select series of RPN reported in published English literature revealed a mean operating time, warm ischemia time, estimated blood loss and hospital stay, of 191 minutes, 25 minutes, 162 ml and 2.95 days, respectively. The overall computed mean complication rate of RPN in the present select series was about 7.4%.

CONCLUSIONS:

RPN is a safe, feasible and effective minimally invasive surgical alternative to laparoscopic partial nephrectomy for early stage (T₁) renal neoplasm(s). It has acceptable initial renal functional outcomes without the increased risk of major complications in experienced hands. Prospective randomised, controlled, comparative clinical trials with laparoscopic partial nephrectomy (LPN) are the need of the day. While the initial oncological outcomes of RPN appear to be favourable, long-term data is awaited.

Current status of partial nephrectomy for renal mass

The standard treatment for a small mass has shifted from radical nephrectomy to partial nephrectomy. The benefits of partial nephrectomy, including preserving renal function, prolonging overall survival, preventing postoperative chronic kidney disease, and reducing cardiovascular events, have been discussed in many studies. With the accumulation of surgeons' experience and simplification of the operative procedures, the warm ischemic time has become shorter despite the indication of tumor size becoming larger. With the help of intraoperative ultrasound, partial nephrectomy can be performed for an endophytic renal mass. Recently, laparoscopic partial nephrectomy has become well indicated for most renal tumors in many centers with advanced laparoscopic expertise. Open partial nephrectomy remains indicated for complex tumors. With technical innovation, robotic partial nephrectomy shows at least comparable perioperative outcomes with a benefit for challenging cases. Laparoendoscopic single-site partial nephrectomy has recently been tried in limited indications and seems to be feasible.

Paediatric robotic-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy (RALIMA): feasibility of and initial experience with the University of Chicago technique

OBJECTIVE

•To present the first series of complete intracorporeal robotic-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendico-vesicostomy (RALIMA) in a paediatric population.

PATIENTS AND METHODS

• From February to November 2008, six patients with neurogenic bladder secondary to spina bifida (status post corrective spine surgery) were selected to undergo RALIMA by a single surgeon (MSG) at the University of Chicago Medical Center. • Patients had constipation, day and night-time incontinence, with recurrent urinary tract infection (UTI), and failed attempts at anticholinergic therapy and clean intermittent catheterization. All had low-capacity bladders with poor compliance and high leak point pressures. • Preoperative bowel preparation was not performed. Mean follow-up is 18 months.

RESULTS

• One patient required conversion to open ileal augmentation because of failure to progress and another underwent augmentation ileocystoplasty without appendico-vesicostomy. The average age of patients was 9.75 years (range 8-11 years). • Average operative time was 8.4 h (range 6-11 h). There were no intraoperative complications. One patient had a postoperative wound infection, one had a lower extremity venous thrombus, and another had temporary unilateral lower extremity paresthesia that has resolved. Three patients required revision of their stoma at the skin-level. • Perioperatively, patients only required oral analgesia for 24-36 h (excluding one patient with paralytic ileus), started on liquid diet after 7.5 hours (range 6-10 h), on regular diet after 24 h (range 12-36 h) and were discharged home within 7 days. • Postoperatively, patients demonstrated no leak on follow-up cystogram, and were catheterizing per apendico-vesicostomy (three patients by 6 weeks) or urethra (1 patient at 4 weeks). • All patients now have day and night-time continence with no UTIs, and bladder capacity of 250-450 mL.

CONCLUSION

• While longer follow-up will be necessary to see if these results are durable, this series demonstrates that RALIMA is a safe, feasible and effective procedure in the short term, with the possible added benefits of reduced analgesia, shorter recovery time and improved aesthetic appearance.

Heminephroureterectomy for duplex kidney: laparoscopy versus open surgery

OBJECTIVE

To report our experience of laparoscopic heminephroureterectomy (Hnu) in pediatric patients with duplex anomalies, in comparison to open surgery.

PATIENTS AND METHODS

Retrospective review of data from patients who underwent Hnu from 2005 to 2008 was performed. The patients were divided into two groups: laparoscopic (LHnu) and open surgery (OHnu). Laparoscopic surgery was performed by transperitoneal approach in majority of cases. Open surgery was performed by retroperitoneal approach in all cases.

RESULTS

Group LHnu: nine patients (8 females, 1 male) with median age of 14 months (range 3-205). Transperitoneal approach was performed in eight patients. Mean operative time was 182 min (CI 95% 146-217). No conversion to open surgery was necessary and there were no complications. Mean hospital stay was 2.44 days (CI 95% 1.37-3.52). Group OHnu: eight patients (3 females, 5 males) underwent nine heminephrectomies at median age of 6.9 months (range 1-12). Mean operating time was 152 min (CI 95% 121-183). There were no complications and mean hospital stay was 4.38 (CI 95% 2.59-6.16) days. Statistical analysis showed no statistically significant difference (P>0.05) in operating time between groups while mean hospital stay was significant (P=0.021).

CONCLUSION

The laparoscopic approach is feasible, safe, reduces hospital stay, does not increase operating time and has better cosmetic results. We believe this should be the first option for heminephrectomy.

Robot-assisted laparoscopic nephrectomy and contralateral ureteral reimplantation in children

BACKGROUND

Robot-assisted laparoscopic surgery (RALS) has expanded the role for minimally invasive surgery within pediatrics. RALS may be particularly beneficial for the treatment of children with a refluxing nonfunctioning renal moiety and contralateral vesicoureteral reflux. In this report, we describe a single RALS procedure, which includes both nephrectomy or partial nephrectomy, and contralateral extravesical ureteral reimplantation (EVUR).

METHODS

A retrospective review was performed of four patients who underwent RALS nephrectomy/partial nephrectomy and concurrent EVUR in one setting. Procedures were performed by a single surgeon using a robot-assisted laparoscopic approach. Four ports were used in a transperitoneal approach with patient positioning changed without moving the robotic system between the nephrectomy and reimplant. We described the technique and assessed its safety and efficacy.

RESULTS

All cases were treated with the single RALS approach. Mean patient age was 2.3 years. Three patients underwent a nephrectomy and one a lower pole partial nephrectomy. The mean estimated blood loss was 16 mL, mean operative time was 291 minutes, and mean length of stay was 2.3 days. There was one case of postoperative ureteral obstruction that was treated with 3 weeks of ureteral stenting without further sequela. Overall, the mean follow-up time was 21 months and follow-up renal ultrasonographs and radionuclide cystograms were normal in all patients.

CONCLUSIONS

A single RALS procedure that combines nephrectomy/partial nephrectomy and EVUR offers a novel approach to a clinical dilemma that often requires two operations. In this small series, RALS was safe and efficacious. We recommend routine Double-J stenting for the solitary reimplanted ureter.

Current trends in pediatric minimally invasive urologic surgery

Over the past two decades, laparoscopic and robotic surgery in children has been described as a viable minimally invasive alternative to open surgery for many pediatric urologic conditions. With the goal of reducing the morbidity associated with open surgery, minimally invasive surgery in children is increasingly being performed as laparoscopic and robotic patients appear to be experiencing shorter hospital stays, decreased pain medication requirements, and the potential for improved cosmesis. This article provides an overview of the existing literature in laparoscopic and robotic-assisted laparoscopic urologic surgery in children. Laparoscopic and robotic-assisted laparoscopic surgery appears to be safe and effective in children for a wide range of ablative and reconstructive procedures. Conventional laparoscopic surgery is effective for ablative procedures, while robotic surgery may be ideally suited for reconstructive cases requiring advanced suturing and dissection. Overall, more prospective studies are needed to study the long-term outcomes of minimally invasive surgery in pediatric patients, and the appropriate use of the available technology.