Laparoscopic pediatric reconstructive surgery remains extremely challenging, with little evidence to demonstrate its superiority over open surgery. The technically demanding nature of this modality has limited its widespread uptake. Adoption of robotic technology in pediatric urologic surgery may help to overcome some of the difficulties experienced with conventional laparoscopy. The early available results with robotically assisted surgery are encouraging and there appears to be a growing body of evidence to support the view that this type of surgery is technically possible and safe. Continued improvements in surgical techniques and equipment should see further reductions in operating times and improvements in perioperative outcomes. The reconstructive nature of pediatric urology lends itself to the advantages of robotic technology particularly with regard to pyeloplasty. The advantages in other areas may not be as good as the current gold standards, particularly due to cost-effectiveness issues.
Pyeloplasty
The gold standard for the treatment of ureteropelvic junction obstruction (UPJO) is open pyeloplasty, with success rates of better than 90%. The first report of the laparoscopic pyeloplasty in a pediatric patient was reported in 1995. Since then, laparoscopic pyeloplasty in children has slowly started to gain widespread acceptance with success rates ranging from 82 to 100%. The most challenging part of a laparoscopic pyeloplasty is the intracorporeal suturing. The operating time for laparoscopic pyeloplasties is longer than that for traditional open pyeloplasties. A number of comparative series have reported statistically significantly longer operating times for minimally invasive pyeloplasty compared with open pyeloplasty. The reintervention rate (7% versus 3%) and redo pyeloplasty rate (4% versus 2%) were higher in the laparoscopic pyeloplasty group than in the open pyeloplasty group.
Robotic pyeloplasty is technically feasible with no significant increase in morbidity. It can be performed by transperitoneal or retroperitoneal route. Transperitoneal robotic pyeloplasty is by far the commonest procedure. The main advantage of a transperitoneal approach is a larger working space that aids intracorporeal suturing. Retroperitoneal robotic procedure can also be performed based on the same concepts as laparoscopic pyeloplasty. Retroperitoneal pyeloplasty allows direct access to the ureteropelvic junction with comparable outcomes to transperitoneal robot-assisted pyeloplasty, but performing the anastomosis retroperitoneally does appear to be more difficult.
The transperitoneal approach in children has been compared with open pyeloplasty in some series. Robotic pyeloplasty was deemed safe and efficacious with the added advantages of decreased hospital stay, decreased narcotic use, and operating times approaching those of open surgery. Da Vinci robot-assisted laparoscopic pyeloplasty was compared with a standard open pyeloplasty in a small series matched by age group. Although robot-assisted laparoscopic pyeloplasty appeared to reduce the length of hospitalization and analgesic requirements, it was associated with a longer mean operating time. Robotic assistance has decreased the time needed to perform an anastomosis but not the overall operating time. The potential benefits of robotic surgery have to be balanced against the associated costs, comprising the initial purchase of the robot and ongoing maintenance costs.
Antireflux surgery
A number of surgical treatment options are available when correction of vesicoureteral reflux (VUR) is indicated. The gold standard treatment is an open ureteral reimplantation (intravesical or extravesical), where success rates in the region of 98 % has been reported.
A recent development is endoscopic submucosal injection of a dextranomer/hyaluronic acid polymer. This minimally invasive option can be extremely effective if two or more injections are used, with long-term outcomes approaching those of open surgery.
The development and progress of laparoscopic antireflux surgery have been slow, mainly because the antireflux procedures require difficult dissection followed by suturing of the bladder. Because of encountering with ureteric injuries during extravesical ureteral reimplantation, the authors advised that age less than 4 years and the presence of concomitant ureteroceles or megaureters are contraindications for this approach. As with other minimally invasive approaches, the benefits include a shorter hospital stay, reduced postoperative pain, and improved cosmesis. Laparoscopic antireflux surgery can be performed reliably by an experienced laparoscopic surgeon, but there is a steep learning curve for this technically demanding procedure.
Robot-assisted antireflux surgery provides an excellent view of the pelvis, with the added benefit of precise suturing of the bladder, ureters, and urethra. Reports have described both extra and intravesical approaches for antireflux surgery in children. With appropriate instrumentation, the pediatric urologist has the ability to angle the instruments during the development of the submucosal tunnel and the suturing of the vesicoureteral anastomosis. A robotically assisted Lich–Gregoir procedure has also been described with a success rate of 97.6% and minimal complications.
Robot-assisted laparoscopic ureteral reimplantation has also been performed successfully via the pneumovesicoscopic approach. Although this procedure is possible, the pneumovesicoscopic approach is highly challenging. A potential problem area regarding robotic surgery is the fact that the current working instruments of the da Vinci system have a diameter of 8 mm and a camera port of 12 mm, which give rise to concerns about bladder closure at the end of the procedure, especially in younger children with a small bladder capacity. The new and smaller 5 mm instruments may remove some of these drawbacks.
Mitrofanoff (appendicovesicostomy) procedure
Laparoscopic construction of continent catheterizable channels such as with a Mitrofanoff procedure has been performed since the mid-1990s. Initial reports described a laparoscopic approach to mobilize the colon and appendix with the reconstruction being performed via an open incision. Then this technically complex procedure can be performed entirely laparoscopically. Robotic Mitrofanoff appendicovesicostomy can also be performed completely intracorporeally. Laparoscopic or robot-assisted Mitrofanoff procedures are technically very challenging but avoid the larger abdominal incisions traditionally employed.
Augmentation cystoplasty
Augmentation cystoplasty is a successful treatment option in the dysfunctional low-capacity bladder. The surgery is most commonly performed using an open approach and can be combined with a bladder neck closure or sling procedure. A laparoscopic approach has not been widely adopted in the pediatric population due to the technically demanding nature of the procedure. The obvious next step was to use the da Vinci platform for this complex reconstructive procedure. The first successful robot-assisted augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy was reported in 2008.
Ureteric reconstructive surgery
A number of groups have successfully described laparoscopic and robot-assisted management of midureteral strictures in the pediatric setting. Both techniques use a trans-peritoneal approach which mirrors open surgery by performing a water-tight spatulated anastomosis over a stent. Laparoscopic ureteroureterostomies with refluxing or ectopic duplex ureters were reported with minimal complications and improvement/resolution of preoperative hydronephrosis. An upper-to-lower pole ureteropyelostomy using conventional laparoscopy and robotic surgery to manage an upper pole ureteral ectopia can also be performed. It is also possible to perform a laparoscopic transureteroureterostomy.
Bladder diverticulum
Bladder diverticulum is an uncommon abnormality in children. It represents a herniation of the bladder mucosa between fibers of the detrusor muscle, resulting in an out pouching into the perivesical space. The exact etiology of congenital bladder diverticulum is not known but is thought to represent an intrinsic weakness in the muscle wall of the bladder. For most urologists, surgical excision by way of the open approach remains the most familiar treatment option. Open bladder diverticulectomy may be performed via an extravesical, intravesical, or combination approach. Laparoscopic bladder diverticulectomy represents a minimally invasive alternative to the open approach and can be performed either transperitoneally or extraperitoneally. Laparoscopic diverticulectomy employs the same principles of the open approach. It should be noted, however, that case series suggest that a staged approach of endoscopic outlet management followed by laparoscopic diverticulectomy results in faster recovery, lower blood loss, and comparable outcomes compared with the combined open approach. Robotic-assisted laparoscopic diverticulectomy also adheres to these treatment principles and represents the most recent major modification to the laparoscopic approach.
