Lessons learned over a decade of pediatric robotic ureteral reimplantation

Abstract

The da Vinci robotic system has improved surgeon dexterity, ergonomics, and visualization to allow for a minimally invasive option for complex reconstructive procedures in children. Over the past decade, robot-assisted laparoscopic ureteral reimplantation (RALUR) has become a viable minimally invasive surgical option for pediatric vesicoureteral reflux (VUR). However, higher-than-expected complication rates and suboptimal reflux resolution rates at some centers have also been reported. The heterogeneity of surgical outcomes may arise from the inherent and underestimated complexity of the RALUR procedure that may justify its reclassification as a complex reconstructive procedure and especially for robotic surgeons early in their learning curve. Currently, no consensus exists on the role of RALUR for the surgical management of VUR. High success rates and low major complication rates are the expected norm for the current gold standard surgical option of open ureteral reimplantation. Similar to how robot-assisted laparoscopic surgery has gradually replaced open surgery as the most utilized option for prostatectomy in prostate cancer patients, RALUR may become a higher utilized surgical option in children with VUR if the adoption of standardized surgical techniques that have been associated with optimal outcomes can be adopted during the second decade of RALUR. A future standard of RALUR for children with VUR whose parents seek a minimally invasive surgical option can arise if widespread achievement of high success rates and low major complication rates can be obtained, similar to the replacement of open surgery with robot-assisted laparoscopic radical prostectomy as the new strandard for men with prostate cancer.

The age of robotic surgery – Is laparoscopy dead?

“…Ureteric re-implantation can be performed easily using the robot, especially as the open technique can be reproduced step-by-step and the published results are excellent. Nevertheless, currently no consensus exists on the role of RALUR for the surgical management of VUR, especially in children, because higher than expected complication rates and lower success rates than previously obtained with the open approach have been reported by some centres [30] .…”

Robotic surgery in pediatric urology: Current status

“…As shown in Table , VUR resolution rates after RALUR ranged from 77% to 100% in the reports included in this study. This variability in success rates after RALUR may have been affected by case selection and a surgeon learning curve . Other possibilities may explain the increased rate of persistent VUR.…”

“…also found that the robotic platform allowed for dissection with minimal nerve disruption, and the enhanced robotic visualization enabled the detection and careful manipulation of the periureteral tissue at the bladder hiatus, allowing delineation of the pelvic plexus . Baek and Koh reported that patients with urinary retention after extravesical ureteral reimplantation were managed by replacing the Foley catheter or employing intermittent catheterization for up to 3 weeks; the retention then usually resolved on it own . Ureteral injury can also be caused by aggressive dissection and devascularization of the ureter from excessive cauterization or by an inadvertent injury to the ureter.…”

Robotic Surgery, Is It the Future?

“…The ability of the robot to filter the physiological human tremors gives it an advantage over the conventional laparoscopic surgery [5]. Robots, therefore, improve the surgeon's dexterity, ergonomics, and visualization [7]. It is intended that by increasing dexterity, controllability and precision to surgeons, robots would allow the execution of more precise and safer operations [3].…”

“…Their role in adrenalectomy is still being evaluated [9]. Robots have been used for robotic guided cardiac radiosurgery for atrial fibrillation, in minimally invasive mitral valve repair and replacement and in paediatric urological operations with different reports on patient's suitability and selection [7,[15][16][17]. There are a growing number of research papers on robotic gastrointestinal surgery.…”