Safety and Efficiency of Various Robot Assisted Laparoscopic Approaches in Pediatric Patients (Our Experience)

We prospectively reviewed 29 consecutive pediatric patients in total of 110 patients with robotic surgery between May 2014 and December 2016.  The total of 29 patients underwent robotic assisted pyeloplasty (n:6), ureteral reimplantation (n:19), augmentation ileocystoplasty (n:2), reduction cystoplasty (n:1) and simple nephrectomy (n:1). All procedures were performed via transperitoneal approach by a single surgeon (Y.K.) who had experience not only open surgery related with pediatric urology but also robotic assisted reconstructive operation in adults. For all cases, indication for surgery, preoperative and postoperative imaging, operation time, blood loss, complication, length of hospital stay were collected. 

The patients with vesicoureteral reflux (VUR) were evaluated with DMSA (dimercaptosuccinic acid), ultrasonography (US), voiding cystouretrography (VCUG) preoperatively. A postoperative US was performed at 1th and 3th month and postoperative VCUG was performed at 3th month. A success of surgery was described as no VUR on postoperative VCUG and resolution of febrile urinary tract infection.

For the patients with vesicoureteral obstruction and ureteropelvic junction obstruction (UPJO), indications of surgery included abnormal diuretic renal sintigraphy and symptoms regarding with obstruction. Following surgery, US was performed at 1th and 3th month, and MAG-3 was performed at 3th month. A regression of hydronephrosis and improvement of drainage in MAG-3 were defined as a successful surgery.

The patients with neurogenic bladder and bladder diverticula were evaluated with videourodynamics and US, preoperatively. DMSA was performed as necessary. Bladder capacity and intact bladder contour were checked with cystography. It was performed at postoperative 1th month for augmentation ileocystoplasty and at postoperative 7th day for reduction cystoplasty. At the same time, regression of hydronephrosis was followed up with US at 1th, 3th, 12th month. For the patient with simple nephrectomy, computed tomography and DMSA were performed preoperatively.

Our Results

• Robotic assisted laparoscopic extravesical ureteral reimplantation (RALUR) was applied to 18 patients with VUR (n:18, ureter units:24) and vesicoureteral obstruction (n:1). The median age was 6,8 years (range 2 to 16 years). Total of 24 ureter units with grade 1-5 reflux in 13 female and 5 male patients were underwent RALUR. The patient with grade 1 reflux had high grade reflux in the opposite site. Patients with grade 5 underwent excisional tailoring was performed before reimplantation. Urethral catheters and silicone drain were removed at the postoperative first day and all patients were discharged at the second day. No perioperative and postoperative complications were seen except one patient who readmitted due to pain on postoperative 4th day. US revealed hydronephrosis and antegrade ureteral stent was inserted. Her ureteral stent was removed at 15th day and 1th month control US revealed normal urinary system. As a result, all patients had complete resolution for reflux. Mean follow-up period was 15,7 months (range 4 to 30 months). The patients did not specify any complaint in follow up. For the patient with vesicoureteral obstruction, improvement of diuretic drainage was observed on MAG-3 renal sintigraphy.

• Robotic assisted laparoscopic pyeloplasty (RALP) was performed to 6 patients (5 males and 1 female) with UPJO. The mean age was 4,5 years (range 1 to 8 years). Two of them had right sided repair and the others had left sided. Two with left UPJO was treated with transmesocolic approach. Silicone drains and urethral catheters were removed at the postoperative first day and all patients were discharged at the postoperative second day. Ureteral stent was removed at postoperative 20th days. Mean follow-up period was 13,2 months (range 9 to 15 months). No intra- and postoperative complications were seen except one patient who had port site bleeding without any transfusion. All patients had regression of preoperative clinical symptoms at the first month and improvement in diuretic renogram at the postoperative 3th month.

• Completely intracorporeal robotic assisted laparoscopic augmentation ileocystoplasty (RLAIC) was applied to two patients with neurogenic bladder. The patients’ ages were 11 and 12 years, respectively. While preoperative total bladder capacities were 150 and 180 cc, postoperative capacities were 340 and 350 cc. No perioperative complications were encountered. Oral fluid intake was started on the postoperative 3th day, the drains were removed at the 4th day and both were discharged at the 15th day after the removal of the urethral catheter. Mean follow-up period was 20,5 months (range 18 to 23 months). The symptoms and preoperative hydronephrosis were also regressed on the first month follow-up. Cystography showed the intact augmented pouch and increased bladder capacity.

• Robotic assisted laparoscopic reduction cystoplasty (RALRC) was performed to 14-year-old boy with a bladder diverticula and recurrent urinary tract infection. The patient had high postvoid residual urine volume (300ml). The portion of the bladder with diverticula was excised and sutured. He was discharged at the postoperative 3th day with no peroperative and postoperative complications. Urethral catheter was removed at 7th day after performing a cystography. 

• The last patient was eleven- year-old female patient with non-functioning kidney. She had recurrent urinary tract infections and was treated with robotic assisted laparoscopic nephrectomy (RALN). The patient was discharged at the postoperative second day without any complication. 

Patient demographics, hospitalization stay, estimated blood loss, robotic time and total operative time were summarized in Table 1.