Robotics and future technical developments in pediatric urology

Minimal Access in Pediatric Surgery: An Overview on Progress towards Dedicated Instrument Developments and Anesthesiologic Advances to Enhance Safe Completion of Procedures

Surgical techniques are evolving in Pediatric Surgery, especially in the area of minimal access surgery (MAS) where indications for applications are expanding. Miniaturization of instruments, using natural orifices, single incisions, or remotely controlled robot-assisted procedures, promises to increase the benefits of MAS procedures in pediatrics. Many pediatric pathologies are rare, and specialized surgical and anesthesiologic instruments are necessary to manage them, defined as "orphan devices", for which development and dissemination on the market are slowed down or sometimes hindered by regulatory standards and limiting financial conflicts of interest. In pediatric surgery, it is of utmost importance to work in a multidisciplinary way to offer a surgical path that is safe and supported by technological advances. For this reason, optimizing pediatric anesthesia is also a crucial factor where technological advances have made monitoring more precise, thereby enhancing safety in the operative room. The development of customized instruments and technologies should be supported by pediatric research and should be adapted to the individualities of the small patient. This overview outlines the importance of dedicated instruments developed for the safe completion of MAS procedures in pediatrics.

Indocyanine green (ICG) fluorescence technology in pediatric robotic surgery

This study aimed to report our experience in indocyanine green (ICG) fluorescence-guided surgery (FGS) in pediatric robotics. The data of 55 patients (35 boys and 20 girls), who underwent robotic surgery using ICG fluorescence in three institutions over the last 7 years, were retrospectively reviewed. The following robotic procedures were included: pyeloplasty (n = 21), complex Lich-Gregoir ureteral reimplantation (n = 8), varicocelectomy (n = 7), adnexal pathology resection (n = 8), partial nephrectomy (n = 4), nephrectomy (n = 4), renal cyst removal (n = 2), and excision of prostatic utricle (n = 1). The ICG was injected intravenously in all indications except for varicocele where intratesticular injection was done, and prostatic utricle or paraureteral diverticulum where trans-catheter injection was done. The ICG dosage was 0.2-0.3 mg/mL/kg. All the procedures were performed using da Vinci Xi platform. Firefly® allowed to switch form bright light to ICG-NIRF view and vice versa. All the procedures were accomplished in robotics without conversions to laparoscopy or open surgery. No episodes of allergy or anaphylaxis to ICG were recorded. An excellent ICG-NIRF view of target organs was obtained in all procedures. Based on our experience, we believe that application of ICG FGS in pediatric robotics enhances the identification of critical anatomical elements and pathological structures, thereby positively impacting both oncological and functional outcomes. This technique is safe, feasible, and versatile. We advocate the consideration of ICG as the standard of care in certain procedures such as partial nephrectomy, varicocele repair, tumor resection, and ovarian torsion. Nonetheless, further investigations are warranted to explore its potential broader applications in pediatric urology.

Robotic-assisted versus conventional laparoscopic ICG-fluorescence lymphatic-sparing palomo varicocelectomy: a comparative retrospective study of techniques and outcomes

PURPOSE

This study aimed to compare techniques and outcomes of robotic-assisted varicocelectomy (RAV) and laparoscopic varicocelectomy (LV).

METHODS

The medical records of 40 patients, who received RAV and LV over a 2-year period, were retrospectively analyzed. Palomo lymphatic-sparing varicocelectomy using ICG fluorescence was adopted in all cases. Three 5-mm trocars were placed in LV, whereas four ports, three 8-mm and one 5-mm, were placed in RAV. The spermatic vessels were ligated using clips in LV and ligatures in RAV. The two groups were compared regarding patient baseline and operative outcomes.

RESULTS

All patients, with median age of 14 years (range 11-17), had left grade 3 varicocele according to Dubin-Amelar. All were symptomatic and 33/40 (82.5%) presented left testicular hypotrophy. All procedures were completed without conversion. The average operative time was significantly shorter in LV [20 min (range 11-30)] than in RAV [34.5 min (range 30-46)] (p = 0.001). No significant differences regarding analgesic requirement and hospitalization were observed (p = 0.55). At long-term follow-up (30 months), no complications occurred in both groups. The cosmetic outcome was significantly better in LV than RAV at 6-month and 12-month evaluations (p = 0.001). The total cost was significantly lower in LV (1.587,07 €) compared to RAV (5.650,31 €) (p = 0.001).

CONCLUSION

RAV can be safely and effectively performed in pediatric patients, with the same excellent outcomes as conventional laparoscopic procedure. Laparoscopy has the advantages of faster surgery, smaller instruments, better cosmesis and lower cost than robotics. To date, laparoscopy remains preferable to robotics to treat pediatric varicocele.

Spine Surgical Robotics: Current Status and Recent Clinical Applications

With the development of artificial intelligence and the further deepening of medical-engineering integration, spine surgical robot-assisted (RA) technique has made significant progress and its applicability in clinical practice is constantly expanding in recent years. In this review, we have systematically summarized the majority of literature related to spine surgical robots in the past decade, and not only classified robots accordingly, but also summarized the latest research progress in RA technique for screw placement such as cervical, thoracic, and lumbar pedicle screws, cortical bone trajectory screws, cervical lateral mass screws, and S2 sacroiliac screws; guiding targeted puncture and placement of endoscope via the intervertebral foramen; complete resection of spinal tumor tissue; and decompressive laminectomy. In addition, this report also provides a detailed evaluation of RA technique's advantages and disadvantages, and clarifies the accuracy, safety, and practicality of RA technique. We consider that this review can help clinical physicians further understand and familiarize the current clinical application status of spine surgical robots, thereby promoting the continuous improvement and popularization of RA technique, and ultimately benefiting numerous patients.

Robotic pyeloplasty learning curve for a pediatric surgeon without previous laparoscopic pyeloplasty experience

Robotic pyeloplasty has become a technique of choice for pyelo-ureteral junction syndrome treatment in children. Less invasive than open surgery, robotic pyeloplasty also has a lower learning curve than laparoscopic pyeloplasty. This is how a new generation of surgeons without previous laparoscopic pyeloplasty experience has begun training in robotics. To assess the robotic assisted pyeloplasty learning curve for a pediatric surgeon only trained in open pyeloplasty, and to investigate if that mode of practice is safe and effective. Data were collected from all children operated on for pyelo-ureteral junction syndrome by the same surgeon in our center between 2015 and 2021. Cases were divided into 4 groups of 14 consecutive procedures to analyze the learning curve. Fifty-six patients were operated on, with a median (IQR) age, weight, and hospital stay of 9 years and 1 month old (3.5), 29 kg (17.3), and 3 days (2), respectively. The mean ± SD operative times were 146.5 ± 39.3, 123.2 ± 48.1, 103.1 ± 29.5, and 141.7 ± 25.0 min, with a unique significant difference between groups 1 and 3 (p = 0.007**). Only two intraoperative and nine postoperative complications were observed. The surgery was successful in 98% cases. Our study shows that a significant improvement in surgical time could be achieved in the first 30 cases, safely and efficiently even without previous laparoscopic pyeloplasty experience.Level of evidence: III.

Prechemotherapy Transperitoneal Robotic-Assisted Partial Nephrectomy (RAPN) for a Wilms Tumor: Surgical and Oncological Outcomes in a Four-Year-Old Patient

BACKGROUND

Wilms tumor (WT) is the most frequent renal tumor in children. The SIOP-UMBRELLA Guidelines allow for nephron-sparing surgery (NSS) in syndromic patients, as well as in cases of small (<300 mL) non-syndromic unilateral WTs, without lymph node involvement, and with a substantial expected remnant renal function, following neoadjuvant chemotherapy. We present a case of prechemotherapy transperitoneal robot-assisted partial nephrectomy (RAPN) for a unilateral, non-syndromic Wilms tumor.

METHODS

A four-year-old child presented with a solid mass measuring 3.6 cm in diameter involving the upper right renal pole, incidentally detected during an abdominal echotomography. CT scan and abdominal MRI revealed no local infiltration or lymph node involvement, suggesting that the exophytic mass could be easily resected via an NSS robotic approach. Preoperative imaging did not strongly suggest WT. A virtual 3D reconstruction of the tumor was performed.

RESULTS

After the oncologic board approval, a robot-assisted partial nephrectomy with an intraperitoneal approach was performed. Histopathological analysis confirmed the diagnosis of WT. The patient subsequently received 10 doses of vincristine as adjuvant chemotherapy. A 28-month follow-up showed no tumor recurrence.

CONCLUSIONS

Intraperitoneal RAPN may be an option for selected WT and warrants consideration as a challenging but advantageous approach.

Economic evaluation of robotic and laparoscopic paraesophageal hernia repair

BACKGROUND

Robotic approach in paraesophageal hernia (PEH) repair may improve outcomes over laparoscopic approach, though at additional cost. This study aimed to compare cost-effectiveness of robotic and laparoscopic PEH repair.

METHODS

A decision tree was created analyzing cost-effectiveness of robotic and laparoscopic PEH repair. Costs were obtained from 2021 Medicare data and were accumulated within 60 months after surgery. Effectiveness was measured in quality-adjusted life-years (QALYs). Branch-point probabilities and costs of robotic surgery consumables were obtained from published literature. The primary outcome of interest was incremental cost-effectiveness ratio (ICER). One-way, two-way, and probabilistic sensitivity analyses were performed. A secondary analysis including attributable capital and maintenance costs of robotic surgery was conducted as well.

RESULTS

Laparoscopic repair yielded 3.660 QALYs at $35,843.82. Robotic repair yielded 3.661 QALYs at $36,342.57, with an ICER of $779,488.62/QALY. Robotic repair was favored when rates of open conversion and symptom recurrence were low, or with reduced cost of robotic instruments. A probabilistic sensitivity analysis favored laparoscopic repair in 100% of simulations. When accounting for costs of robotic technology, robotic approach was preferred only in unrealistic clinical scenarios.

CONCLUSIONS

Laparoscopic repair is likely more cost-effective for most institutions, though results were relatively similar. With experienced surgeons who surpass the initial learning curve, robotic surgery may improve outcomes enough to be cost-effective, but only when excluding capital and maintenance fees.

Senhance Robotic Platform in Pediatrics: Early US Experience

INTRODUCTION

Different robotic systems have been used widely in human surgery since 2000, but pediatric patients require some features that are lacking in the most frequently used robotic systems.

HYPOTHESIS

The Senhance^® robotic system is a safe and an effective device for use in infants and children that has some advantages over other robotic systems.

METHODS

All patients between 0 and 18 years of age whose surgery was amenable to laparoscopy were offered enrollment in this IRB-approved study. We assessed the feasibility, ease and safety of using this robotic platform in pediatric patients including: set-up time, operative time, conversions, complications and outcomes.

RESULTS

Eight patients, ranging from 4 months to 17 years of age and weighing between 8 and 130 kg underwent a variety of procedures including: cholecystectomy (3), inguinal herniorrhaphy (3), orchidopexy for undescended testes (1) and exploration for a suspected enteric duplication cyst (1). All robotic procedures were successfully performed. The 4-month-old (mo), 8 kg patient underwent an uneventful robotic exploration in an attempt to locate a cyst that was hidden in the mesentery at the junction of the terminal ileum and cecum, but ultimately the patient required an anticipated laparotomy to palpate the cyst definitively and to excise it completely. There was no blood loss and no complications. Robotic manipulation with the reusable 3 mm instruments proved successful in all cases.

CONCLUSIONS

Our initial experience with the Senhance^® robotic platform suggests that this is a safe and effective device for pediatric surgery that is easy to use, and which warrants continued evaluation. Most importantly, there appears to be no lower age or weight restrictions to its use.

Applications of Indocyanine Green-Guided Near-Infrared Fluorescence Imaging in Pediatric Minimally Invasive Surgery Urology: A Narrative Review

Background: Indocyanine green (ICG) is a fluorescent dye used for several indications in adult surgery, and, more recently, adopted also in the pediatric patients. This study aimed to review the literature published on the use of ICG near-infrared fluorescence (NIRF) in pediatric urology, to address its shortcomings and disadvantages and to detect the future perspectives. Materials and Methods: An electronic literature search of PubMed on all studies reporting use of ICG-NIRF in pediatrics was performed. We included only studies reporting ICG-NIRF application in minimally invasive surgery (MIS) for pediatric urology indications. Results: Forty-two articles reporting MIS procedures performed using ICG-NIRF in children were obtained, but only 15 studies that focused on urological applications of ICG-NIRF in children were included in this review. The included studies described use of ICG-NIRF for kidney malformations such as duplex system, kidney tumors, renal cysts, ureteral pathology, bladder malformations, varicocele, and lymph node sampling in tumors. The pediatric urological applications in which ICG-NIRF provided significant advantages included partial nephrectomy, lymphatics sparing varicocele repair, and oncological procedures. The ICG-NIRF use was clinically safe, without reported adverse systemic reactions in all pediatric series. The main drawback of this technology is the need of specific laparoscopic equipment such as camera system, light sources, and telescopes or the da Vinci Xi Robot, with the software for ICG-NIRF, Firefly^®, already integrated within. Conclusions: ICG-enhanced fluorescence-guided surgery is gaining growing popularity among pediatric surgeons due to the excellent results that have been published until now. ICG-NIRF technology has proven to be safe, easy to use, not time-consuming, cheap, and very effective to improve intraoperative view and surgical ability. Nonetheless, further evidence, including larger series, longer follow-up, and more specific assessments, is necessary to confirm the preliminary results and enlarge the applications.

Learning Curves in Pediatric Robot-Assisted Pyeloplasty: A Systematic Review

Background: Robot-assisted surgery demands a specific skillset of surgical knowledge, skills, and attitudes from the robotic surgeon to function as part of the robotic team and for maximal utility of the assistive surgical robot. Subsequently, the learning process of robot-assisted surgery entails new modes of learning. We sought to systematically summarize the published data on pediatric robot-assisted pyeloplasty (pRALP) to decipher the learning process by analyzing learning curves. Methods: This review followed the PRISMA guidelines. PubMed, EMBASE, Web of Science, and Scopus databases were systematically searched for ‘learning curve’ AND ‘pediatric pyeloplasty’. All studies presenting outcomes of learning curves (LC) in the context of pRALP in patients < 18 years of age were included. Studies comparing LC in pRALP versus open and/or laparoscopic pyeloplasty were also included; however, those solely focusing on LC in non-robotic approaches were excluded. The methodological quality was assessed using the Newcastle and Ottawa scale. Results: Competency was non-uniformly defined in all fifteen studies addressing learning curves in pRALP. pRALP was considered safe at all stages. Proficiency in pRALP was reached after 18 cases, while competency was estimated to demand 31 operated cases with operative duration as outcome variable. Conclusions: Pediatric RALP is safe during the learning process and ‘learning by doing’ improves efficiency. Competencies with broader implications than time must be defined for future studies.

Robotic partial nephrectomy for complex kidney cyst in a 4-year old boy: Points of technique

Complex kidney cysts are rarely observed in childhood. In adult patients, when radiological studies found a suspicious renal lesion, the gold standard is surgical asportation. The robotic surgery is well known as a secure procedure for treatment these patients, and is nowadays a real alternative also for pediatric patients. The challenges in children surgery are linked to anesthesiologic gestion, smaller operative fields, the need of specific instruments and more delicate tissue handling. We present a step-by-step video description of a robotic partial nephrectomy for a renal multicystic mass in a 4 year-old child.

Robotic Surgery in Pediatric Urology: A Critical Appraisal of the GECI and SIVI Consensus of European Experts

Background: This study aimed to create a consensus statement on the indications, applications, and limitations of robotics in pediatric urology. Methods: After a panel and interactive discussion focused on pediatric robotics, a televoting with 10 questions was administered to 100 pediatric surgeons/urologists attending the joint meeting of the French Group of Pediatric Laparoscopy (GECI)/Italian Society of Videosurgery in Infancy (SIVI) in 2021. The results of televoting were analyzed electronically using Mentometer software. Results: Ninety-four percent of participants stated that the cutoff weight for robotics should be >10-15 kg. A minimum of 20-30 procedures should be performed to become confident in robotics (74%). Pediatric urology is the main field of application (73%) and pyeloplasty is the best indication for robotics (63%). Technical problems may happen intraoperatively in 1/10-15 cases (64%). The mean duration of robotic procedures ranges from 150 to 200 minutes (72%). The main drawbacks of robotics are high costs and limited development of miniaturized instruments (74%). Ninety-five percent believed that the costs of robotics may significantly drop with the availability of more robotic brands. The main advantages of robotics over laparoscopy include improved dexterity, easier suturing, and better ergonomics (100%), whereas the main disadvantage of sharing the robot with other specialties is the wearing out of instruments (100%). Conclusions: This is the first consensus statement, endorsed by the GECI and SIVI societies, on the use of robotics in pediatric urology. The need to introduce more robotic brands on the market to lower the costs and to develop miniaturized instruments to be adopted in infants less than 10 kg emerged. Pediatric urology is the main field of application of pediatric robotics, and robotic pyeloplasty is the most common procedure performed. Proctorship is needed for the first 20-30 procedures and technical problems may occur intraoperatively in 1/10-15 cases. The main advantages of robotics over laparoscopy are improved dexterity, easier suturing, and better surgeon ergonomics.

Comparison of the Safety and Efficacy of Laser Versus Pneumatic Intracorporeal Lithotripsy for Treatment of Bladder Stones in Children

This study aimed to compare the safety and efficacy of laser lithotripsy and pneumatic lithotripsy, the two most commonly used transurethral lithotripsy methods for treating bladder stones in children in Iraq. Between January 2013 and December 2016, 64 children with bladder stones were included in this prospective randomized study, after ethical committee approval and written consent from the children’s parents or caregivers were obtained. Patients were assigned randomly by computer software to two groups treated with either pneumatic cystolithotripsy or laser lithotripsy. A 9 Fr. semirigid ureteroscope was used to pass the lithotripter through and fragment the stone. A catheter of 8–12 Fr. was then introduced and kept in place for 24 h. All children were hospitalized for 24 h, and the catheter was removed the next morning. Outpatient follow-up was maintained for 6–12 months. In terms of operation outcomes and complications, the laser lithotripsy group had a significantly longer duration of operation (74.5 ± 26.6 min vs. 51.5 ± 17.2 min, p = 0.001), whereas the number of patients requiring an extended hospital stay was significantly higher in the pneumatic lithotripsy group (48.5% vs. 16.1%, p = 0.006). Moreover, pneumatic lithotripsy was associated with a significantly greater risk of having at least one adverse effect (64% greater than that in the laser group). Stone clearance rates did not significantly differ between treatment groups. In conclusion, both pneumatic and laser lithotripters can be used to treat children with bladder stones with high efficacy and safety.