Role of Robotics in Children: A brave New World!

Has robot-assisted pyeloplasty reached outcome parity with laparoscopic pyeloplasty in children <15 kg? A Paediatric YAU international multi-center study

INTRODUCTION

Ureteropelvic Junction Obstruction (UPJO), is a major cause of pathological hydronephrosis in children. Minimally invasive surgery (MIS), including laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP), has gained popularity due to its known advantages. LP faces technical difficulties and a steep learning curve. RALP has overcome these limitations, making it safer and more effective for children. The study aims to assess the safety and effectiveness of LP and RALP in infants weighing ≤15 kg.

MATERIALS AND METHODS

This is a retrospective analysis (2010-2022). The study included pediatric patients who had a confirmed diagnosis of UPJO and weighed ≤15 kg. The patients were divided into two groups: LP and RALP. The study evaluated preoperative, intraoperative, perioperative, and follow-up data, including complications. Success was defined as no worsening of hydronephrosis on postoperative ultrasound in the first year of follow-up.

RESULTS

The total patients were 94: 42 in the LP group, and 52 in the RALP group. The median age at the intervention was 17.5 months (LAP group) versus 29 months (RALP group) (p = 0.01). The median weight at the time of intervention was 9.5 Kg (LP group), and 11.6 Kg (RALP group) (p = 0.44). The median operative time was significantly longer in the LP group: 245 min versus 125.5 min in the RALP group (p = 0.001). The median length of hospitalization was comparable: 4.3 days (LP group) and 3.5 days (RALP group) (p = 0.42). No intraoperative complications were reported in either group. There were no statistically significant differences regarding postoperative complications. During follow-up, all patients remained asymptomatic, with no episodes of urinary tract infection or abdominal pain, and none of them had a recurrence of UPJ obstruction. Consequently, the two techniques are equally effective and safe in the short term.

DISCUSSION

Both procedures offer excellent outcomes with comparable postoperative complications. LOS was similar for both groups, with no intraoperative complications or conversions, and a non-significant increase in postoperative complications. A notable finding was the significant difference in operation times between the procedures, emphasizing the importance of reduced surgical time in pediatric patients for minimizing anesthetic and intubation durations.

CONCLUSION

For the absence of intra- and postoperative complications and recurrences, RALP is as effective as LP in pyeloplasty in children weighing 15 kg or less. This finding reinforces the idea that RALP can be safely executed, benefiting from its advanced technology and the learning curve, for patients of any age regarding pyeloplasty for UPJO.

A Pilot Study to Determine the Role of Spatulating the Ureter During Pyeloplasty in Children for Ureteropelvic Junction Obstruction in the Robotic Era

Purpose: Spatulation during ureteropelvic junction obstruction repair was evaluated in children treated by robot-assisted retroperitoneal pyeloplasty anastomosis (RRPA). Methods: Intraoperative video recordings (IVRs) of RRPA (n = 22 ureters) performed at a single institute between 2018 and 2022 were reviewed blindly by 5 independent surgeons for perceived difficulty of suturing (DOS; 5 = impossible; 4 = difficult; 3 = tedious; 2 = slow; 1 = easy) and spatulation ranking as superior (+1), inferior (-1), or unnecessary (0). The retroperitoneal space was accessed in the lateral decubitus position using a closed technique under direct vision to avoid air leakage and subcutaneous emphysema. All subjects had a Double-J stent (4.7F) placed. Results: Subjects had similar demographics and preoperative ureter diameters. IVRs were RRPA with spatulation of the ureter on the lateral side (RRPA +SP) (n = 13) and RRPA without spatulation of the ureter (RRPA -SP) (n = 9). Overall DOS scores and coefficients of variation for time taken to place one suture were similar. Total anastomotic time was significantly shorter for RRPA -SP; 67.9 ± 8.4 minutes versus 57.9 ± 9.2 minutes, P = .01. Overall spatulation ranking was 0. Postoperative scanning showed improved drainage in 12 of 13 (92%) in RRPA +SP and 8 of 9 (88%) in RRPA -SP; differences were not significant. One anastomotic stricture in RRPA -SP required open repair. Conclusions: RRPA was quicker and more precise without spatulation. Outcomes of scanning 1 year after RRPA were similar for RRPA -SP and RRPA +SP.

Robotic-assisted surgery for gynecological indications in children and adolescents: European multicenter report

Robotic-assisted surgery (RAS) is increasingly adopted in the pediatric population. This retrospective multicenter study aimed to report application of RAS for gynecological indications in pediatric patients. The medical records of all girls with gynecological pathology, operated in 4 different institutions over a 3-year period, were retrospectively collected. Robot docking time, total operative time, length of stay (LOS), requirement time of pain medication, complication rate, conversion rate, and pathology were analyzed. Twenty-three girls, with median age of 12.3 years (range 0.6-17.8) and median weight of 47.2 kg (range 9-73), received the following RAS procedures: ovarian cystectomy for ovarian cyst/mass (n = 10), salpingo-oophorectomy for ovarian complex mass (n = 6), bilateral gonadectomy for Turner syndrome SRY + (n = 1), salpingectomy for fallopian tube lesion (n = 1), paratubal cyst excision (n = 1), Gartner cyst excision (n = 1), paravaginal ganglioneuroma resection (n = 1), fistula closure in urogenital sinus (n = 1), and vaginoplasty using ileal flap in cloaca malformation (n = 1). Median operative time was 144.9 min (range 64-360), and median docking time was 17.3 min (range 7-50). Conversion to open or laparoscopy was not necessary in any case. Median LOS was 2.1 days (range 1-7), and median analgesic requirement was 2.2 days (range 1-6). One patient (4.3%) needed redo-surgery for recurrent Gartner cyst (Clavien 3b). This preliminary experience showed that RAS is safe and feasible for surgical treatment of gynecological pathology in pediatric patients, although no conclusive data are available to confirm its superiority over traditional laparoscopy. Randomized, prospective, comparative studies are needed to identify the gold standard approach for such indication.

Evaluation of the Versius Robotic System for Infant Surgery-A Study in Piglets of Less than 10 kg Body Weight

BACKGROUND

We were able to demonstrate the feasibility of a new robotic system (Versius, CMR Surgical, Cambridge, UK) for procedures in small inanimate cavities. The aim of this consecutive study was to test the Versius^® system for its feasibility, performance, and safety of robotic abdominal and thoracic surgery in piglets simulating infants with a body weight lower than 10 kg.

METHODS

A total of 24 procedures (from explorative laparoscopy to thoracoscopic esophageal repair) were performed in 4 piglets with a mean age of 12 days and a mean body weight of 6.4 (7-7.5) kg. Additional urological procedures were performed after euthanasia of the piglet. The Versius^® robotic system was used with 5 mm wristed instruments and a 10 mm 3D 0° or 30° camera. The setup consisted of the master console and three to four separate arms. The performance of the procedure, the size, position, and the distance between the ports, the external and internal collisions, and complications of the procedures were recorded and analyzed.

RESULTS

We were able to perform all surgical procedures as planned. We encountered neither surgical nor robot-associated complications in the live model. Whereas all abdominal procedures could be performed successfully under general anesthesia, one piglet was euthanized early before the thoracic interventions, likely due to pulmonary inflammatory response. Technical limitations were based on the size of the camera (10 mm) being too large and the minimal insertion depth of the instruments for calibration of the fulcrum point.

CONCLUSIONS

Robotic surgery on newborns and infants appears technically feasible with the Versius^® system. Software adjustments for fulcrum point calibration need to be implemented by the manufacturer as a result of our study. To further evaluate the Versius^® system, prospective trials are needed, comparing it to open and laparoscopic surgery as well as to other robotic systems.

Pediatric robotic surgery: issues in management-expert consensus from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP)

BACKGROUND

Pediatric robotic-assisted surgeries have increased in recent years; however, guidance documents are still lacking. This study aimed to develop evidence-based recommendations, or best practice statements when evidence is lacking or inadequate, to assist surgical teams internationally.

METHODS

A joint consensus taskforce of anesthesiologists and surgeons from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP) have identified critical areas and reviewed the available evidence. The taskforce comprised 21 experts representing the fields of anesthesia (n = 11) and surgery (n = 10) from clinical centers performing pediatric robotic surgery in the Italian cities of Ancona, Bologna, Milan, Naples, Padua, Pavia, Perugia, Rome, Siena, and Verona. Between December 2020 and September 2021, three meetings, two Delphi rounds, and a final consensus conference took place.

RESULTS

During the first planning meeting, the panel agreed on the specific objectives, the definitions to apply, and precise methodology. The project was structured into three subtopics: (i) preoperative patient assessment and preparation; (ii) intraoperative management (surgical and anesthesiologic); and (iii) postoperative procedures. Within these phases, the panel agreed to address a total of 18 relevant areas, which spanned preoperative patient assessment and patient selection, anesthesiology, critical care medicine, respiratory care, prevention of postoperative nausea and vomiting, and pain management.

CONCLUSION

Collaboration among surgeons and anesthesiologists will be increasingly important for achieving safe and effective RAS procedures. These recommendations will provide a review for those who already have relevant experience and should be particularly useful for those starting a new program.

Application and prospects of robotic surgery in children: a scoping review

As an innovative minimally invasive surgical technology, robot-assisted surgery (RAS) has greatly improved the accuracy and safety of surgery through the advantages of three-dimensional magnification, tremor filtering, precision and flexibility, and has been carried out by an increasing number of surgeries. In recent years, robots have been gradually applied to children, bringing new ideas and challenges to pediatric surgeons. This review will describe the advantages and limitations of robotic surgery in children, summarize its application in pediatric surgery, and provide an outlook. It is believed that clinicians should actively carry out RAS under the premise of rigorously ensuring surgical indications and strive to improve the efficacy of surgical treatment for children.

Laparoscopic and robot-assisted ureterocalicostomy for treatment of primary and recurrent pelvi-ureteric junction obstruction in children: a multicenter comparative study with laparoscopic and robot-assisted Anderson-Hynes pyeloplasty

Purpose

This multi-institutional study aimed to assess the outcomes of laparoscopic ureterocalicostomy (LUC) and robot-assisted laparoscopic ureterocalicostomy (RALUC) and compare them with laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP) in children with pelvi-ureteric junction obstruction (PUJO).

Methods

The data of 130 patients (80 boys), with median age 7.6 years and median weight 33.8 kg, receiving minimally invasive treatment of PUJO over a 6-year period, were retrospectively analyzed. Patients were grouped according to the operative approach: G1 included 15 patients, receiving LUC (n = 9) and RALUC (n = 6), and G2 included 115 patients, receiving LP (n = 30) and RALP (n = 85). Patient characteristics and operative outcomes were compared in both groups.

Results

The median patient age and weight were significantly higher in G1 than in G2 [p = 0.001]. The median operative time was similar in both groups (157.6 vs 150.1 min) [p = 0.66] whereas the median anastomotic time was shorter in G1 than in G2 (59.5 vs 83.1 min) [p = 0.03]. The surgical success rate was similar in both groups (100% vs 97.4%) [p = 0.33]. Post-operative complications rate was higher in G1 than in G2 (20% vs 6.1%) but all G1 complications were Clavien 2 and did not require re-intervention.

Conclusion

LUC/RALUC can be considered safe and effective alternative approaches to LP/RALP for PUJO repair and reported excellent outcomes as primary and salvage procedures. Robot-assisted technique was the preferred option to treat most patients with recurrent PUJO in both groups.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11255-022-03305-2.

Robotic Surgery: Is There a Possibility of Increasing Its Application in Pediatric Settings? A Single-Center Experience

Introduction: Robotic surgery has shown explicit benefits and advantages in adults, but it is not yet strongly established in the pediatric population, even though its popularity is increasing, especially in the urologic field. Materials and methods: In this article we present our experience with the Da Vinci System (SI first and XI nowadays) at our pediatric institution in order to analyze our progress over the years. We considered all patients from the start of the robotic surgery program in 2016 until the end of 2021, dividing them into general abdominal surgery and genitourinary surgery. Analyzed data were the patient's demographic, details of surgery, and intra and post-operative complications. Results: The total number of patients (pts) included in this study was 76, of whom 40 (52%) were male and 36 (48%) were female. The mean age at surgery was 90.9 months (range 10-207 months), and the mean weight at surgery was 29.3 kg (range 9.5-68 kg). There were 18 general abdominal robotic surgeries and 58 genitourinary robotic surgeries performed. The most performed surgeries in these two categories were fundoplication for gastro-oesophageal reflux disease (11%) and Anderson-Hynes pyeloureteroplasty. The mean operative time was 224.2 min (range 72-530 min): the mean times in the two groups (general abdominal surgery and genitourinary surgery) were 165 min (range 84-204 min) and 194 min (range 95-360 min), respectively. A total of four (5%) minor complications were reported. The total conversions were two (2.6%) and the mortality rate was 0%. Conclusions: Pediatric robotic surgery is a field of considerable interest and it is rapidly expanding. In our experience, it is evident how the learning curve has increased gradually, but steadily, allowing us to advance from standardized surgery, such as fundoplication and pieloplasty, towards a more technically complex one, achieving the same good results. We believe that robotic surgery is very respectful of tissues and feasible, especially for reconstructive surgery. For these reasons, it could become of common use also in the pediatric population, overcoming impediments such as excessive cost and the lack of pediatric instruments, in order to be able to treat children with a progressively lower age and weight.

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.

Rise of pediatric robotic surgery in Italy: a multicenter observational retrospective study

Background

The minimally invasive surgery (MIS) in term of robot-assisted surgery changed in a dramatic way the surgical approach either in adults or children. For many specialties (urology, gynecology, general surgery) robotic surgery rapidly became the gold standard for some procedures, while the experience in pediatric population is not wide for some reasons. The aim of this study is to retrospective analyze trends of application of robotic surgery in pediatric patients across the country, focusing on indications, limitations, development, and training acquired by national experience and in comparison to the literature.

Methods

We made a retrospective multicenter study on behalf of Italian Society of Pediatric Surgery. We performed a census among all pediatric surgery units in the country to enroll those performing robotic surgery on children between 2013 and 2019.

Results

We enrolled 7 pediatric surgery referral Centers (Ancona, Bologna, Brescia, Genova, Pavia, Pescara, Siena). A total of 303 patients were included in the study, 164 males (54%) and 139 females (46%). The most commonly performed interventions for each anatomic area were respectively atypical pulmonary resection (38%), pyeloplasty (49%), and fundoplication (30%).

Conclusions

Since its first application in Italy, about 10 years ago, several considerations were made about application and feasibility of robotics in children.

Robotics and future technical developments in pediatric urology

Minimally invasive surgery (MIS) has represented the main innovation in the field of pediatric surgery and urology over the last 30 years. Pediatric MIS is a wide field, ranging from the standard laparoscopic surgery using 3-mm ports to robotics mainly adopted for pediatric urology indications. The aim of this paper was to summarize the current status of robotic surgery in pediatric urology and to evaluate possible future technical developments for this technique. In pediatric urology, many procedures are challenged by the narrow working space available in smaller children, the difficulty to perform complex and long suture lines to repair complex urinary malformations, and the challenge to remove renal or adrenal tumors. The main characteristic of robotic surgery is that the robotic instruments inserted into the abdominal cavity are remotely controlled by the surgeon, who is sitting at a console next to the patient or even far away, avoiding human tremor during complex suturing. Due to the magnification of the operative field view and the six degrees of freedom of the robotic instruments compared to conventional laparoscopic instruments, providing enhanced 3D vision and improved surgeon ergonomics, robot-assisted surgery appears to be beneficial over conventional MIS, especially in complex reconstructive procedures. Currently, there are two robotic systems available on the market and certified for robotic surgery in children: the DaVinci (Intuitive Surgical, since 2001) and Senhance (Transenterix, since 2020). However, almost the totality of papers published in the international literature are focused on robotic procedures using the DaVinci platform. Analyzing the current literature, there is no evidence about the indications where robotics are preferable to conventional MIS approaches. Currently, the main indications of robotic surgery in pediatric urology are: pyeloplasty for ureteropelvic junction obstruction (UPJO), ureteral reimplantation according to Lich Gregoire technique, Mitrofanoff procedure, nephrectomy or partial nephrectomy for oncological indications, removal of renal cysts, bladder neck reconstruction or removal of urinary tract stones. The future developments in this field are certainly represented by intraoperative use of indocyanine green (ICG) fluorescence imaging that permits to have a better vision of vascular anatomy or clearly identify nodes in case of tumors, and by development of 5G technology. The main limitation of robotic surgery today remains the excessive cost of the machine itself and the limited lifespan of robotic instruments. We believe that robotic surgery will surely represent the new field of development in pediatric surgery, but its widespread application will depend on the introduction of new robotic platforms in the market, that will certainly low the costs, and also to the development of smaller size instruments more suitable for pediatric use.

Anesthetic Implications of Robotic-Assisted Surgery in Pediatric Patients

The novel technology of robotic-assisted surgery (RAS) has been utilized in children for the past two decades with several potential clinical benefits including reduction of postoperative pain, shortened hospital length of stay, and improved cosmetic outcomes. While associated costs and the limitations regarding instruments for smaller pediatric patients remain relevant issues, surgeon comfort related to ergonomic design in combination with enhanced three-dimensional high-fidelity imaging and tissue handling compared to traditional minimally invasive approached may offer improved surgical and postoperative outcomes. Given that the demand for this innovative technology will likely continue to expand in the field of pediatric surgery, pediatric anesthesiologists will be called upon to provide anesthetic care to patients exposed to this novel surgical technology with its unique features, intraoperative requirements, and potential complications. The current manuscript provides a narrative review of robotic-assisted surgery and discusses important anesthetic considerations and potential complications of these techniques.

Robot-assisted laparoscopic surgery for treatment of urinary tract stones in children: report of a multicenter international experience

This study aimed to report a multi-institutional experience with robot-assisted laparoscopic surgery (RALS) for treatment of urinary tract stones in children. The medical records of 15 patients (12 boys), who underwent RALS for urolithiasis in 4 international centers of pediatric urology over a 5-year period, were retrospectively collected. The median patient age was 8.5 years (range 4–15). Eleven/fifteen patients (73.3%) had concurrent uretero–pelvic junction obstruction (UPJO) and 2/15 patients (13.3%) had neurogenic bladder. Stones were in the renal pelvis in 8/15 (53.3%), in the lower pole in 3/15 (20%), in the bladder in 2/15 (13.3%), and in multiple locations in 2/15 (13.3%). One patient (6.6%) had bilateral multiple kidney stones. The median stone size was 10.8 mm (range 2–30) in upper tract location and 27 mm (range 21–33) into the bladder. Eleven patients with concomitant UPJO underwent simultaneous robot-assisted pyelolithotomy and pyeloplasty in 12 kidney units. Two patients with isolated staghorn stones received robot-assisted pyelolithotomy. Robot-assisted cystolithotomy was performed in two patients with bladder stones. The median operative time was 131.8 min (range 60–240). The stone-free rate was 80% following initial surgery and 100% after secondary treatment. Clavien 2 complications (hematuria, infections) were recorded in 5/15 patients (33.3%). Three/fifteen patients (20%) with residual renal stones were successfully treated using ureterorenoscopy (Clavien 3b). RALS was a feasible, safe and effective treatment option for pediatric urolithiasis in selected cases such as large bladder stones, bilateral kidney stones, staghorn stones or concomitant anomalies such as UPJO requiring simultaneous pyeloplasty.

Comparative analysis of outcomes and long-term follow-up of robot-assisted pediatric kidney transplantation, with open counterpart

How does the robotic kidney transplant fare against the open technique, in pediatric patients? No one knows. To address this question, this study compares the outcomes of robotic kidney transplants, with those of open transplant in these patients. This study was a retrospective analysis of outcomes (renal function and complications), of all pediatric patients (<18 years of age), who underwent kidney transplant at our institute, after 2014, till their last follow-up. Fisher's exact test was used to compare proportions. Continuous variables were analyzed using Mann-Whitney test. P value of <.05 was considered significant. Of the twenty-five patients included, 21 belonged to open group, and 4 to the robotic group. Patients in the robotic group had significantly higher Re-WIT (P value .002) and had lower analgesia requirement (P value .04). Median follow-up period was 31 months. Both groups were comparable in terms of length of hospital stay, blood transfusion, and renal function post-operatively till their last follow-up. Three patients in the open group had surgical site infection as compared to none in the robotic group. All the patients had functioning grafts till their last follow-up. Robotic transplant is safe and delivers functional results similar to open technique, with lesser pain and better cosmesis. Longer Re-WIT in robotic transplant has no impact on post-operative renal function. Ours is the first known effort to compare robotic technology with the established open technique of transplant in this population. A prospective randomized controlled trial should refine the results of the present study.

Robotic infant surgery with 3 mm instruments: a study in piglets of less than 10 kg body weight

No data exist concerning the appication of a new robotic system with 3 mm instruments (Senhance®, Transenterix) in infants and small children. Therefore, the aim of this study was to test the system for its feasibility, performance and safety of robotic pediatric abdominal and thoracic surgery in piglets simulating infants with a body weight lower than 10 kg. 34 procedures (from explorative laparoscopy to thoracoscopic esophageal repair) were performed in 12 piglets with a median age of 23 (interquartile range: 12–28) days and a median body weight of 6.9 (6.1–7.3) kg. The Senhance® robotic system was used with 3 mm instruments, a 10 mm 3D 0° or 30° videoscope and advanced energy devices, the setup consisted of the master console and three separate arms. The amount, size, and position of the applied ports, their distance as well as the distance between the three operator arms of the robot, external and internal collisions, and complications of the procedures were recorded and analyzed. We were able to perform all planned surgical procedures with 3 mm robotic instruments in piglets with a median body weight of less than 7 kg. We encountered two non-robot associated complications (bleeding from the inferior caval and hepatic vein) which led to termination of the live procedures. Technical limitations were the reaction time and speed of robotic camera movement with eye tracking, the excessive bending of the 3 mm instruments and intermittent need of re-calibration of the fulcrum point. Robotic newborn and infant surgery appears technically feasible with the Senhance® system. Software adjustments for camera movement and sensitivity of the fulcrum point calibration algorithm to adjust for the increased compliance of the abdominal wall of infants, therefore reducing the bending of the instruments, need to be implemented by the manufacturer as a result of our study. To further evaluate the Senhance® system, prospective trials comparing it to open, laparoscopic and other robotic systems are needed.

Pediatric Challenges in Robot-Assisted Kidney Transplantation

Kidney transplantation is universally recognized as the gold standard treatment in patients with End-stage Kidney Disease (ESKD, or according to the latest nomenclature, CKD stage 5). Robot-assisted kidney transplantation (RAKT) is gradually becoming preferred technique in adults, even if applied in very few centra, with potentially improved clinical outcomes compared with open kidney transplantation. To date, only very few RAKT procedures in children have been described. Kidney transplant recipient patients, being immunocompromised, might be at increased risk for perioperative surgical complications, which creates additional challenges in management. Applying techniques of minimally invasive surgery may contribute to the improvement of clinical outcomes for the pediatric transplant patients population and help mitigate the morbidity of KT. However, many challenges remain ahead. Minimally invasive surgery has been consistently shown to produce improved clinical outcomes as compared to open surgery equivalents. Robot-assisted laparoscopic surgery (RALS) has been able to overcome many restrictions of classical laparoscopy, particularly in complex and demanding surgical procedures. Despite the presence of these improvements, many challenges lie ahead in the surgical and technical–material realms, in addition to anesthetic and economic considerations. RALS in children poses additional challenges to both the surgical and anesthesiology team, due to specific characteristics such as a small abdominal cavity and a reduced circulating blood volume. Cost-effectiveness, esthetic and functional wound outcomes, minimal age and weight to undergo RALS and effect of RAKT on graft function are discussed. Although data on RAKT in children is scarce, it is a safe and feasible procedure and results in excellent graft function. It should only be performed by a RAKT team experienced in both RALS and transplantation surgery, fully supported by a pediatric nephrology and anesthesiology team. Further research is necessary to better determine the value of the robotic approach as compared to the laparoscopic and open approach. Cost-effectiveness will remain an important subject of debate and is in need of further evaluation as well.

Advances and Trends in Pediatric Minimally Invasive Surgery

As many meta-analyses comparing pediatric minimally invasive to open surgery can be found in the literature, the aim of this review is to summarize the current state of minimally invasive pediatric surgery and specifically focus on the trends and developments which we expect in the upcoming years. Print and electronic databases were systematically searched for specific keywords, and cross-link searches with references found in the literature were added. Full-text articles were obtained, and eligibility criteria were applied independently. Pediatric minimally invasive surgery is a wide field, ranging from minimally invasive fetal surgery over microlaparoscopy in newborns to robotic surgery in adolescents. New techniques and devices, like natural orifice transluminal endoscopic surgery (NOTES), single-incision and endoscopic surgery, as well as the artificial uterus as a backup for surgery in preterm fetuses, all contribute to the development of less invasive procedures for children. In spite of all promising technical developments which will definitely change the way pediatric surgeons will perform minimally invasive procedures in the upcoming years, one must bear in mind that only hard data of prospective randomized controlled and double-blind trials can validate whether these techniques and devices really improve the surgical outcome of our patients.

Robot-assisted laparoscopic pyeloplasty (RALP) in children with complex pelvi-ureteric junction obstruction (PUJO): results of a multicenter European report

PURPOSE

This study aimed to report a multi-institutional retrospective case series of outcomes after robot-assisted laparoscopic pyeloplasty (RALP) in pediatric patients with complex pelvi-ureteric junction obstruction (PUJO).

METHODS

All patients undergoing complex RALP over the last 5 years were included. RALP was defined complex in the following cases of PUJO: anatomic variations including ectopic, malrotated, horseshoe, or duplex kidney and recurrent PUJO after failed open pyeloplasty.

RESULTS

Forty-eight patients underwent complex RALP in four European centers in the study period and included 18 girls and 30 boys with a median age of 8 years (range 5-12). The PUJO was associated with anatomic variations in 35/48 (72.9%), whereas a recurrent PUJO was present in 13/48 (27.1%). A dismembered Anderson-Hynes pyeloplasty was performed in all patients. The median operative time including docking was 178.5 min (range 117-255) and the median anastomotic time was 64.8 min (range 50-76). All patients were discharged on 2nd postoperative day (POD). The median follow-up was 18.2 months (range 14-43). The overall success rate was 95.8% (46/48). Early postoperative complications (< 30th POD) included urinary tract infections (UTIs) and stent-related irritative symptoms in 4/48 (8.3%) [II Clavien], whereas late complications (> 30th POD) included recurrence of PUJO in 2/48 (4.2%), who needed re-operation [IIIb Clavien].

CONCLUSIONS

RALP was safe, feasible, and with good mid-term outcome in complex PUJO. An accurate pre-operative planning, a standardized technique, and an experienced surgical robotic team represented key points to manage successfully such complex cases.

Minimally Invasive Management of Bladder Stones in Children

Background: Bladder stones (BS) are rare in children. Minimally invasive surgery (MIS) seems to be nowadays the procedure of choice to treat pediatric patients with BS. This study aimed to analyze retrospectively our experience with percutaneous cystolithotomy, endourological treatment with Holmium laser and robotic cystolithotomy in children with BS. Methods: We retrospectively analyzed the data of 13 children (eight boys and five girls) with BS who were treated at our centers between July 2013 and July 2020. The patients received three different MIS procedures for stones removal: five underwent robotic cystolithotomy, five underwent endourological treatment and three received percutaneous cystolithotomy (PCCL). We preferentially adopted endourological approach for stones <10 mm, percutaneous approach between 2014 and 2016 and robotic approach since 2016 for larger stones. Results: Mean patients' age at the time of diagnosis was 13 years (range 5-18). Ten/13 patients (76.9%) had primary BS and 3/13 patients (23.1%) had secondary BS. Mean stone size was 18.8 mm (range 7-50). In all cases the stones were removed successfully. One Clavien II post-operative complication occurred following PCCL (33.3%). All the procedures were completed without conversions. Operative time ranged between 40 and 90 min (mean 66) with no significant difference between the three methods (p = 0.8). Indwelling bladder catheter duration was significantly longer after PCCL (mean 72 h) compared with robotic and endourological approaches (mean 15.6 h) (p = 0.001). Hospitalization was significantly longer after PCCL (mean 7.6 days) compared with the other two approaches (mean 4.7 days) (p = 0.001). The endourological approach was the most cost-effective method compared with the other two approaches (p = 0.001). Conclusions: Minimally invasive management of bladder stones in children was safe and effective. Endourological management was the most cost-effective method, allowing a shorter hospital stay compared with the other procedures but it was mainly indicated for smaller stones with a diameter < 10 mm. Based upon our preliminary results, robotic surgery seemed to be a feasible treatment option for BS larger than 15-20 mm. It allowed to remove the big stones without crushing them with a safe and easy closure of the bladder wall thanks to the easy suturing provided by the Robot technology.

Robot-assisted vs laparoscopic pyeloplasty in children with uretero-pelvic junction obstruction (UPJO): technical considerations and results

BACKGROUND

Although both laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP) have reported excellent clinical outcomes, no evidence is currently available about the best surgical approach for surgical treatment of children with uretero-pelvic junction obstruction (UPJO).

OBJECTIVE

This study aimed to compare the outcomes of LP and RALP in children with UPJO.

STUDY DESIGN

The medical records of all patients with UPJO, who underwent LP or RALP in three pediatric urology units over a 2-year period, were retrospectively reviewed. The authors excluded open pyeloplasty and cases with complex anatomy such as horseshoe kidney. A dismembered Anderson-Hynes pyeloplasty was performed in all cases.

RESULTS

Sixty-seven patients (39 boys and 28 girls) with a median age of 4 years (range 8 months-14 years) were included. Thirty-seven patients (55.2%) underwent RALP, and 30 patients (44.8%) underwent LP. Three patients of RALP group presented a recurrent UPJO. No significant difference was found in the median total operative time between RALP (133 min) and LP (139 min) (P = 0.33). The median anastomotic time was significantly shorter in RALP (79 min) compared with LP (105.5 min) (P = 0.001). Overall surgical success rate was 96.7% for LP and 100% for RALP (P = 0.78). As for postoperative complications, the authors recorded re-stenosis of UPJO in one LP patient (3.3%), who underwent redo-RALP.

DISCUSSION

According to the authors experience, robotic surgery should be indicated in patients older than 18-24 months with a body weight > 10-15 Kgs. Laparoscopic pyeloplasty requires advanced laparoscopic skills related to intracorporeal suturing. However, the learning curve of suturing in robotics is much shorter compared with laparoscopy. In fact, during LP, the authors have to place 2-3 transabdominal stay sutures to stabilize the uretero-pelvic junction, before performing the anastomosis. Conversely, the authors never needed to place stay sutures in RALP.

CONCLUSIONS

The study experience suggested that RALP and LP give excellent results in children with UPJO. Laparoscopic pyeloplasty can be considered more minimally invasive than RALP because 3-mm trocars are adopted instead of 8-mm robotic ports. However, LP is technically challenging and has a bad ergonomics for the surgeon. Conversely, RALP is technically easier compared with LP, especially in redo procedures, with an excellent ergonomics. The main disadvantages of RALP remain high costs and size of robotic instruments. The choice to perform LP or RALP should be tailored to the individual case, considering patient's age and surgeon's experience.

Single-setting robot-assisted kidney transplantation consecutive to single-port laparoscopic nephrectomy in a child and robot-assisted living-related donor nephrectomy: initial Ghent experience

INTRODUCTION

Kidney transplantation (KT) is the gold-standard treatment for end-stage renal disease (ESRD) in children. Robot-assisted kidney transplantation (RAKT) in adults is becoming increasingly common with potentially improved morbidity compared with open KT. The study objective was to evaluate feasibility and outcomes of RAKT in children.

PATIENTS & METHODS

An 8-years-old boy with ESRD received a kidney transplant from his mother. Simultaneously in two operation theatres, the boy underwent single-port (GelPOINT®) right laparoscopic nephro-ureterectomy (LNU), and his mother underwent robot-assisted left donor nephrectomy (RADN).Two full surgical teams were operating at the same time. Subsequently, the boy underwent RAKT, introducing the graft through the GelPOINT®.

RESULTS

Total operative time for LNU, RADN, and RAKT was 180, 140, and 195 min, respectively, with warm, cold, and rewarming ischemia times 1.5, 200, and 47 min, respectively. Blood loss was 300, 20, and 50 cc, respectively. No intraoperative complications were noted. Convalescence of both donor and recipient was uneventful, with good kidney function at 1-year follow-up.

CONCLUSION

RAKT in children is technically feasible and safe, resulting in excellent graft function. Concomitant nephrectomy can be done laparoscopically through the single-site GelPOINT®. An experienced RAKT team with the full support of pediatric nephrologists is mandatory.

Cost, training and simulation models for robotic-assisted surgery in pediatric urology

INTRODUCTION

Laparoscopic procedures in pediatric urology have been shown to be safe and effective over the last number of years. Coupled with this is the technological trend to provide minimally invasive options for even the most complex pediatric patients. Whilst robotic platforms continue to try to demonstrate superior patient outcomes in adults with mixed results, the utilization of robotic platforms for pediatric urology is increasing.

METHODS

A review of the current literature was undertaken to assess the evidence for training models and cost-effectiveness of robotic-assisted pediatric urology.

CONCLUSIONS

A growing body of evidence in this field has demonstrated that robotic platforms are safe and effective in children and can provide additional reconstructive benefits due to motion scaling, magnification, stereoscopic views, instrument dexterity and tremor reduction. The main drawbacks remain the financial implications associated with this platform through purchase, maintenance, and disposable costs. This review addresses some of the addresses issues pertaining to cost, training and simulation for robotic-assisted surgery in pediatric urology.

Robotic Urologic Surgery in Infants: Results and Complications

Over the last 30 years, robotic surgery has evolved into the preferred surgical approach for many operative cases. Robotics has been associated with lower pain scales, shorter hospitalizations, and improved cosmesis (1, 2). However, its acceptance in pediatrics have been hampered by longer operative times, smaller working space, and limited fine surgical instruments. Many find these challenges even more pronounced when performing robotic surgery in infants (i.e., children <1 year old). Although the data in infants is less robust, many studies have shown benefits similar to the adult population. Specifically, multiple reports of robotic surgery in infants have shown lower postoperative analgesic use. Additionally, hospital stays are shorter, which may lead to quicker return to work for parents and guardians. Multiple reports have shown low complication rates of robotic surgery in infants. When complications have occurred, they are usually Clavien Grade 1 and 2, with occasional grade 3. Often the complications are not from the robotic technique, but are linked to other factors such as the ureteral stents (3, 4). Most importantly, the success rates of surgery are comparable to open surgery. This chapter will review indications for the most common urologic robotic surgeries performed in infants. Also, we will review reported results and complications of robotic surgery in children, with specific attention to the infant population. However, data focused only on infants is limited. Many studies have some infant patients, but their results are often mixed with all pediatric patients.

Evaluation of a new robotic-assisted laparoscopic surgical system for procedures in small cavities

No data exists concerning the application of a new robotic system with 3-mm instruments (Senhance™, Transenterix, Milano, Italy) in small cavities. Therefore, the aim of this study was to test the system for its performance of intracorporal suturing in small boxes simulating small body cavities. Translucent plastic boxes of decreasing volumes (2519-90 ml) were used. The procedures (two single stitches, each with two consecutive surgical square knots) were performed by a system-experienced and three system-inexperienced surgeons in each box, starting within the largest box, consecutively exchanging the boxes into smaller ones. With this approach, the total amount of procedures performed by each surgeon increased with decreasing volume of boxes being operated in. Outcomes included port placement, time, task completion, internal and external instrument/instrument collisions and instrument/box collisions. The procedures could be performed in all boxes. The operating time decreased gradually in the first three boxes (2519-853 ml), demonstrating a learning curve. The increase of operating time from boxes of 599 ml and lower may be attributed to the increased complexity of the procedure in small cavities as in the smallest box with the dimensions of 2.9 × 6.3 × 4.9 cm. This is also reflected by the parallel increase of internal instrument-instrument collisions. With the introduction of 3-mm instruments in a new robotic surgical system, we were able to perform intracorporal suturing and knot tying in cavities as small as 90 ml. Whether this system is comparable to conventional three-port 3-mm laparoscopic surgery in small cavities-such as in pediatric surgery-has to be evaluated in further studies.

Pediatric Robotic Surgery in South America: Advantages and Difficulties in Program Implementation

Robotic assisted laparoscopic surgery is gaining popularity around the world due to its vast benefits. Although it has been established mainly in developed countries, in South America the robotic programs have become more popular, but its growth is clearly slower. Information about robotic pediatric surgery program in Brazil, Chile, Uruguay, and Argentina was collected through e-mail surveys. Results were analyzed and compared to worldwide information about robotic surgery. Due to the wide social, economical, and technological gap between hospitals in South America, it is hard to develop a proper pediatric robotic surgery program. The main obstacles in those four countries appear to be a combination of high purchase costs and equipment maintenance, lack of financial coverage of the procedure by insurance companies and the absence of significant benefits proved in pediatrics in relation to laparoscopic surgery. The pediatric specialties are in the process of making and implementing robotic programs supported by the evident development in adult specialties. However, pediatric robotic surgery in Brazil, Chile, Uruguay and Argentina do not seems to share that growth.

Robotic Ureteral Reconstruction in the Pediatric Population

Robot-assisted laparoscopic (RAL) surgery is a safe, minimally invasive technique that has become more widely used in pediatric urology over recent decades. With several advantages over standard laparoscopy, robotic surgery is particularly well-suited to reconstructive surgery involving delicate structures like the ureter. A robotic approach provides excellent access to and visualization of the ureter at all levels. Common applications include upper ureteral reconstruction (e.g., pyeloplasty, ureteropelvic junction polypectomy, ureterocalicostomy, and high uretero-ureterostomy in duplex systems), mid-ureteral reconstruction (e.g., mid uretero-ureterostomy for stricture or polyp), and lower ureteral reconstruction (e.g., ureteral reimplantation and lower ureter-ureterostomy in duplex systems). Herein, we describe each of these robotic procedures in detail.