VIEWS: 291 PAGES: 10

									Scandinavian Journal of Surgery 98: 110–119, 2009


P. Casale1, Y. Kojima1, 2
1   Division of Urology, the Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia,
    Pennsylvania, U.S.A
2   Department of Nephro-Urology, Nagoya City University Graduate School of Medical Sciences,
    Nagoya, Japan


Laparoscopic procedures for urological diseases in children, such as nephrectomy, pyelo-
plasty and orchiopexy, have proven to be safe and effective with outcome comparable to
the open procedure. However, main drawback has been the relatively steep learning
curve for this procedure because of technical difficulties of suturing and anastomosis.
More recently, robotic-assisted laparoscopic surgery (RAS) has gained enormous popu-
larity in adult urology and is increasingly being adopted around the world; however, few
pediatric urology series have been reported. RAS has several advantages over conven-
tional laparoscopic surgery, with the main advantage being simplification and precision
of exposure and suturing because of allowing movements of the robotic arm in real time
with increased degree of freedom and magnified 3-dimentional view. These features
render RAS ideal for complex reconstructive surgery in a pediatric urological population.
This review discusses the role of RAS in pediatric urology, and provides some technical
aspects of RAS and a critical summary of current knowledge on its indications and out-
come. Almost all operations that are classically performed as open or conventional
laparoscopic reconstructive surgery for children with urological anomalies could be re-
placed by RAS, which may be established as an alternative minimally invasive surgery
in the future.
Key words: Robotics; laparoscopy; minimally invasive surgery; pediatrics; urology; urinary tract

INTRODUCTION                                             since it has several advantages over standard open
                                                         surgery, including more rapid recovery, increased
Recent advances in equipment and surgical tech-          magnification improving visualization, improved
niques have made minimally invasive surgery (MIS)        cosmetic outcome, less postoperative pain, and con-
a well tolerated and efficient technique. Laparoscopic   sequently, lower analgesic requirements, and shorter
surgery has gained acceptance as a feasible and reli-    hospital stays. Conventional laparoscopic procedures
able treatment associated with minimal morbidity,        for urological diseases in children, such as nephrec-
                                                         tomy, pyeloplasty and orchiopexy, have also proven
                                                         to be safe and effective with outcome comparable to
Correspondence:                                          the open procedure. However, main drawback has
  Pasquale Casale, M.D.
  Children’s Hospital of Philadelphia
                                                         been the relatively steep learning curve for this pro-
  34th Street and Civic Center Boulevard                 cedure because of technical difficulties of suturing
  Wood Building 3rd Floor                                and anastomosis.
  Philadelphia, PA 19107, U.S.A.                            On the other hand, robotic-assisted surgery (RAS)
  Email:                           has gained enormous popularity in adult urology,
                                       Robotic-assisted laparoscopic surgery in pediatric urology: an update                   111

                               TABLE 1                                     tion (UPJO). Recently, there has been many other
 Procedures and indications of robotic-assisted laparoscopic surgery in    procedures that can be performed with the robot such
                          pediatric urology.                               as ureteral reimplantation, and nephrectomy, both
                                                                           total and partial (2, 3). The reconstructive aspect has
Procedures                     Indications                                 been taken to the next level where more difficult pro-
Nephrectomy                    Nonfunctioning kidney                       cedures, such as appendicovesicostomy and bladder
                               Multicystic dysplastic kidney               augmentation can be performed in children (Table 1).
                               Single-system ectopic ureter                Although long-term outcome analysis of pediatric
                               Malignancy                                  urology series have remained largely unexplored and
                               Pediatric kidney recipients                 this recently developed technique has not been estab-
Heminephroureterectomy         Duplication anomalies(ectopic ureter        lished in a pediatric urological population, this has
                               or ureterocele)                             been expected to have greatly expanding the indica-
(Partial nephrectomy)            nonfunctioning upper pole kidney          tion of many pediatric urological anomalies.
                                 cystic malformation of the upper             This review discusses the role of RAS in pediatric
                                 pole kidney
                                 nonfunctioning refluxing lower
                                                                           urology, and provides our technical aspects and a
                                 pole kidney                               critical summary of current knowledge on its indica-
                                                                           tions and outcome in the literature.
Pyeloplasty                    Ureteropelvic junction obstruction
Ureterocalicostomy             Ureteropelvic junction obstruction
                                 significant lower pole calicectasis       GENERAL TECHNIQUES
                                 failed pyeloplasty
                                 minimal pelvis                            Typically, an open access technique is used for the
                                 exaggerated intrarenal pelvis             12-mm camera port. We usually place camera port in
                                                                           the superior aspect of the umbilicus. The abdomen is
Ureteroureterostomy            Duplication anomalies(ectopic ureter        insufflated with CO2 at a pressure of 10–15 mm Hg to
                               or ureterocele)
                                 functioning upper pole kidney
                                                                           observe the inside of the abdominal cavity clearly
                                                                           using a 12-mm, 0-degree telescope. A 5 mm endo-
Pyelolithotomy                 Kidney stone                                scope is available but is monocular and cannot pro-
Ureteral reimplantation        Vesicoureteral reflux                       vide the 3-D image of the larger scope. Two addi-
  Vesicoscopic approach                                                    tional working 5-mm trocars are usually inserted. The
  Extravesical approach                                                    robotic device is docked from the ipsilateral side in
Appendicovesicostomy           Bladder outlet obstruction and              the upper urinary tract surgery or the foot of the bed
                               dysfunction                                 in the lower urinary tract surgery and orchiopexy,
(+Bladder augmentation)          neuropathic bladder                       and the robotic arms are engaged. The robot has in-
                                 nonneurogenic neurogenic                  struments that are available in both 8 and 5 mm sizes.
                                 bladder                                   A fourth arm is available for grasping and retraction.
                                 posterior urethral valves                 We utilize Maryland bipolar forceps as a grasper, and
                                 exstrophy-epispadias complex              either monopolar hook device or curved scissors dur-
Bladder neck sling             Intrinsic sphincter deficiency              ing dissection. Robotic needle driver can make sutur-
Orchiopexy                     Nonpalpable testis (intraabdominal
                                                                           ing easier. The techniques and technology have
                               testis)                                     evolved allowing identical results and utilizing 5-0,
                                                                           6-0, and 7-0 suture as in open surgeries.

                                                                           INDICATIONS, PROCEDURES AND OUTCOMES IN
                                                                           PEDIATRIC UROLOGY

and especially, robotic-assisted laparoscopic radical                      Nephrectomy
prostatectomy for the patients with localized prostate
cancer is increasingly being adopted around the                            Indication
world (1). The daVinci surgical system (Intuitive Sur-                     Indications for nephrectomy may be poor or nonfunc-
gical, Sunnyvale, CA, USA) provides the advantages                         tioning kidney related to UPJ obstruction, due to
of simplification and precision of exposure and sutur-                     stones or refluxing nephropathy, a multicystic dys-
ing because of allowing movements of the robotic                           plastic kidney, malignancy such as renal cell carci-
arm in real time with increased degree of freedom                          noma and Wilms tumor, and pediatric kidney recipi-
and magnified 3-dimentional (3-D) view. Therefore,                         ents (5–7). In addition, one of the most satisfying
RAS has a possibility to overcome many impediments                         applications is in the diagnosis and therapy of the
of conventional laparoscopic surgery and decreased                         single-system ectopic ureter in girls presenting uri-
the learning curve for MIS, especially for pediatric                       nary incontinence (8).
reconstructive procedures (2, 3). RAS also allows the
seasoned laparoscopist to become more proficient                           Surgical technique
and refined providing a greater “tool box” to expand                       Simple nephrectomy is somewhat of an overkill of
MIS to more complex reconstructive procedures (4).                         technology however, robotic advantages such as the
   The procedure most performed in pediatric urol-                         3-D images, increased dexterity, and decreased learn-
ogy is pyeloplasty for ureteropelvic junction obstruc-                     ing curve can be advantages for beginners (9). Neph-
112                                              P. Casale, Y. Kojima

rectomy can be performed using transperitoneal or
retroperitoneal approaches, but the transperitoneal
operation is the most readily accomplished due to the
size of the ports and the arms especially in the infant
population. In the transabdominal approach, the pa-
tient is placed in a modified flank position with a 60°
elevation of the flank (Fig. 1). Ports are placed in the
umbilicus for the camera port, midline above the um-
bilicus and mid clavicular line below the umbilicus,
for the working ports. In infants, the upper working
port should be placed sub-xyphoid in the midline
and the lower working port as lateral a possible to the
rectus muscle. The robot is docked over the ipsilateral
shoulder. The procedure is performed as described
for the laparoscopic approach. The choice of the
transperitoneal or retroperitoneal approach depends
on the surgeon’s experience. It may be influenced by
the need for additional procedures such as complete
nephroureterectomy and bladder access if ureteral
reimplantation is required. Retroperitoneal access is
distinct in port placement and patient positioning.
Ports are placed posteriorly or laterally depending
upon surgeon preference. The size of the robotic arms
makes a posterior approach more difficult except in
older children (i.e., over 12 years).
As described above, robotic-assisted nephrectomy is
possible in children with some advantages. RAS of-
fers promise but expense currently limits its use (10).
There is no report on outcome study of robot-assisted
nephrectomy and little information in the literature
is available on their pediatric use at the present           Fig. 1. A modified flank position with a 60° elevation of the flank
time.                                                        for transabdominal approach

Heminephroureterectomy (partial nephrectomy)
Indication                                                   needed, one can readily turn to the bladder for repair.
Indication for heminephrouretectomy (HNU) and                The robot typically needs to be re-docked from the
partial nephrectomy includes duplication anomalies           foot of the bed. A bladder catheter is kept in place
such as a nonfunctioning upper pole kidney with              overnight and the patient can be discharged the same
ectopic ureter or ureterocele, cystic malformation of        or next day.
the upper pole kidney, and a nonfunctioning reflux-          Outcome
ing lower pole kidney (11). Since the children with a
duplication anomaly present with a clear vascular            Pedraza et al. reported the first case of bilateral
and anatomic plane to be followed between upper              RAHNU for a 4-year girl presented with recurrent
and lower pole kidney, robotic-assisted HNU                  urinary tract infections and urinary incontinence (12).
(RAHNU) is a good indication for these children.             Olsen et al. performed RAHNU using the retroperi-
                                                             toneal approach for 14 girls with 176 min of median
Surgical technique                                           operative time. In two patients, the procedure was
RAHNU may also be performed transperitoneally or             converted to an open operation (13). Recently, Lee et
retroperitoneally. Again, due to the size of the ports       al. have reported the safety and feasibility of RAHNU
and robot arms, we prefer to use the transperitoneal         in children (11). It was completed successfully in
approach. RAHNU is similar to complete nephrec-              9 cases with a mean operative time of 275 minutes
tomy with regard to port placement and initial expo-         and an estimated blood loss of 49 ml. All patients
sure of the ureters and hilum. The transection of the        had a normal remaining renal moiety after the opera-
affected moiety may be done either with the hook or          tion and the only complication was an asymptomatic
scissor cautery. Prior to patient positioning, an open       urinoma.
ended ureteral catheter in the unaffected moiety is
placed cystoscopically, in order to inject methylene         Pyeloplasty
blue after diseased moiety transection to ensure there
is no leakage. The procedure is carried out as de-
scribed for the laparoscopic approach. I prefer the          UPJO is characterized by a functionally significant
transperitoneal approach because if bladder access is        impairment of urinary transport caused by an intrin-
                               Robotic-assisted laparoscopic surgery in pediatric urology: an update                              113

sic or extrinsic obstruction in the area where the ure-
ter joins the renal pelvis. The main goals of treatment
are the relief of symptoms and the preservation of
renal function. Open pyeloplasty remains the stan-
dard surgical repair; however, laparoscopic pyelo-
plasty and robotic-assisted laparoscopic pyeloplasty
(RAP) have recently been described as a feasible re-
constructive procedure in children with UPJO. RAP
offers significant benefit because of the precision in
Surgical technique
RAP can be performed also by a trans- or retroperi-
toneal approach. We typically utilize 6-0 monofila-
ment absorbable suture, but one can utilize any 5-0
or 6-0 suture depending on the size of the patient. We
do not recommend anything larger than 6-0 for small
children and infants. The patient is placed in the same            Fig. 2. Robotic-assisted laparoscopic pyeloplasty; a double pigtail
position and robotic docking is performed as for ne-               stent is being placed after the posterior wall closure is complete.
phrectomy. UPJ is exposed trans-mesenterically on
the left or by mobilizing the colon on the right. If one
chooses colonic mobilization on the left, it must be
taken medially over the aorta. The surgical proce-                 demonstrated that RAP had advantages of decreased
dures follow the same rules as the conventional lap-               hospital stay and decreased narcotic use in compari-
aroscopic approach. A hitch stitch is passed through               son with open pyeloplasty, although operative times
the abdominal wall and is placed to elevate and sta-               were increased relative to open pyeloplasty (16, 17).
bilize the pelvis if so desired. We use a hitch stitch if          Although we previously presented our early small
a pyelolithotomy is necessary. After the pelvis is in-             experience with RAP in infants, and demonstrated all
cised, the ureter is spatulated laterally and the anas-            of nine infants 3 to 8 months old successfully under-
tomosis is performed using a running suture. A dou-                went RAP, a larger comparison study had been
ble pigtail stent is placed after the posterior wall clo-          needed to evaluate fully the outcomes of this ap-
sure is complete (Fig. 2). This is performed by placing            proach based on patient age (19), because smaller
an 18 gauge angiocatheter through the anterior ab-                 workspace may be a limitation for robotic perfor-
dominal wall. A guide wire is then placed in an ante-              mance in laparoscopy (21). In addition, robot-assisted
grade fashion. The stent is then passed over the guide             laparoscopic “reoperative” pyeloplasty in children
wire. We recommend filling the bladder with saline                 with persistent UPJO after open surgical correction is
or methylene blue so one can observe the efflux of                 also reported to be a safe and effective option in the
urine when there is access into the bladder by the                 treatment of these challenging indications (22, 23).
stent. The stent can also be placed retrograde to use
a dangling string to allow removal in the office. Ure-
thral catheter is left for overnight bladder drainage              Ureterocalicostomy
and double J ureteral stent is taken out in 2–4 weeks              Indication
Outcome                                                            Robotic-assisted ureterocalicostomy (RAUC) is a po-
The results described in the literature show similar               tential option in patients with UPJO and significant
success as the ‘‘gold standard’’ open procedure of                 lower pole calicectasis, patients with failed pyelo-
around 95% (14–20). Atug et al. performed RAP suc-                 plasty and a minimal pelvis, or patients with an exag-
cessfully for seven children and demonstrated that no              gerated intrarenal pelvis (24).
patient required additional procedures postopera-
tively (15). In addition, Olsen et al. performed robot-            Surgical technique
ic-assisted retroperitoneoscopic pyeloplasty for 65                A transperitoneal approach is implemented. The co-
children and demonstrated that success rate was 94%                lon is reflected, exposing the massively dilated kid-
(18). On the other hand, two reports compared an age               ney. The ureters are transected and ligated with ab-
matched cohort undergoing open pyeloplasty to RAP                  sorbable sutures at the level of the renal pelvis or
in children for safety and efficacy (17,18). Yee et al.            crossing vessels if the pelvis is not readily accessible.
reported that 8 pediatric patients underwent RAP                   The ureters are spatulated before transection. The
and were matched by age group with patients under-                 most dependent lower pole calix is amputated with
going open pyeloplasty, and all robotic procedures                 hot shears. There is a minimal amount of bleeding
were successful as determined by subjective data us-               from the thinned parenchyma of the lower pole sys-
ing pain scales and radiologic data (16). Additionally,            tem, and the electrocautery of the hot shears easily
Lee et al. also performed a retrospective case-control             controlled any bleeding. The posterior anastomosis is
study 33 patients undergoing RAP and 33 undergo-                   performed with 5-0 absorbable suture in a running
ing open pyeloplasties, and reported that RAP were                 fashion (Fig. 3). The ureteral stent is then placed in
done a success rate of 93.9% (17). These two reports               the same fashion of RAP, as described above. The
114                                                       P. Casale, Y. Kojima

                                                                      We perform robotic-assisted ureteroureterostomy
                                                                      (RAUU) for children with a duplicated collecting sys-
                                                                      tem, showing an upper pole ectopic ureter with func-
                                                                      tion in that moiety, although typically a common
                                                                      sheath reimplantation or HNU seems to be the treat-
                                                                      ment of choice for ectopia. We preserve the affected
                                                                      moiety if it shows function on preoperative studies
                                                                      typically by a common sheath reimplantation or up-
                                                                      per tract reconstruction depending on concomitant
                                                                      entities, i.e. lower pole reflux or the necessity of blad-
                                                                      der neck reconstruction with ectopia.
Fig. 3. Robotic-assisted laparoscopic ureterocalicostomy; an anas-    Surgical techniques
tomosis between lower pole calyx and ureter with 5-0 absorbable
suture in a running fashion.
                                                                      The surgical procedure includes transperitoneal ap-
                                                                      proach. All patients undergo cystoscopic evaluation
                                                                      with retrograde ureteropyelogram and open-ended
                                                                      ureteral catheter placement into the lower pole ureter
anterior anastomosis is performed in an interrupted                   prior to robotic intervention. The external portion of
manner, allowing visualization and approximation of                   the ureteral catheter is secured to the urethral catheter
the renal collecting system to the ureteral mucosa                    and prepped into the operative laparoscopic field.
without placing tension on the renal parenchyma.                      Access to the open ended ureteral catheter during the
The anterior sutures are then tied in groups so that                  operation is paramount. The catheter is instilled with
the last few suture placements are unobstructed and                   methylene blue as needed to ensure the integrity of
precise. The stent is removed at 6 weeks after surgery                the collecting system and the anastamosis. The ure-
with a retrograde ureteropyelogram to visualize the                   teral catheter also assures access for placement of an
anastomosis.                                                          indwelling stent after the posterior anastomosis is
                                                                      completed. The upper pole ectopic ureter is spatu-
Outcome                                                               lated before transection. Re-approximations of the
We performed RAUC for nine patients with UPJO                         upper pole ureter to the lower pole ureter are per-
(mean age 6.5). Mean operative time was 168 minutes                   formed with 6-0 absorbable suture in a running fash-
and mean hospital stay was 21 hours (24). There was                   ion (Fig. 4). All the distal ureteral segment to the va-
no evidence of obstruction after operation in any pa-                 gina is removed at the level of the vagina. The upper
tient.                                                                pole ectopic ureter in the boy to the prostate is re-

                                                                                                   Figure 4. Robotic-assisted lap-
                                                                                                   aroscopic ureteroureterostomy;
                                                                                                   Re-approximations of the upper
                                                                                                   pole ureter to the lower pole
                                                                                                   ureter with 6-0 absorbable su-
                                                                                                   ture in a running fashion.
                               Robotic-assisted laparoscopic surgery in pediatric urology: an update                             115

moved at the level of the prostate via the same trans-
peritoneal approach. We do not leave ureteral stumps
when we perform these procedures laparoscopically
due to the relative easy access via a transperitoneal
An earlier experience on both laparoscopic and ro-
botic complex upper tract reconstruction in children
with duplicated systems found the approach both at
the renal level and the bladder level to be easier to
perform in a robotic fashion as compared to a laparo-
scopic fashion (25). Passerotti et al. have reported that
RAUU for the correction of ureteral obstruction in
children is a reliable and efficient technique, and can
be applied to any pathology that requires ureteral
reconstruction, regardless if it is a duplicated or a              Fig. 5. Robotic-assisted laparoscopic ureteral reimplantation (ex-
single system (26).                                                travesical approach); mobilization of the ureter is done using the
                                                                   hook or scissor cautery.

Ureteral reimplantation
Indication                                                         using the hook or scissor cautery (Fig. 5). The submu-
Primary vesicoureteral reflux (VUR) is a common                    cosal tunnels are created by dissecting with scissors
anomaly affecting the vesico-ureteric junction, and                from the original hiatus to the other side of the trig-
open ureteral reimplantation is the established pro-               one, and incising the mucosa at the site of the new
cedure for managing it surgically. Indication of ure-              mucosal hiatus. Anastomosis of the ureters is per-
teral reimplantation includes breakthrough infec-                  formed after bringing them through the mucosal tun-
tions, worsening reflux, and higher grade reflux.                  nel. Anchoring sutures of 4-0 absorbable suture are
Subureteral injection of implant materials has also                used to secure the ureter to the bladder musculature
shown much promise in recent years, with success                   and the mucosal cuff is attached with 5-0 absorbable
rates approaching open surgery after 2 or more injec-              suture. The mucosa over the original hiatus is closed
tions. Successful laparoscopic reimplantation has ad-              with running 5-0 absorbable. If the patient had previ-
ditionally been described (27). Robotics can be also               ous injection therapy, it should be removed. The
implemented in the different techniques of ureteral                working ports are removed and the bladder holding
reimplantation, i.e. extravesicle and vesicoscopic                 stitches are then tied. The flexible cystoscope is used
(28–32).                                                           to inspect the inside of the bladder. The port sites are
                                                                   also closed at the fascial level. The bladder catheter
                                                                   is kept overnight.
Vesicoscopic approach
Surgical technique
                                                                   There are few reports of this approach using conven-
The laparoscopic Cohen procedure using a pneumo-                   tional laparoscopy (27) and only one using robotic
vesicum was first described in a pig model in 2003                 assistance (31). Peters et al (31) reported their 5 cases
(30). Its limitations have been described and the au-              experiences of robotic-assisted transvesical crosstrig-
thors do not advocate the approach in bladder less                 onal reimplantation (Cohen procedure). However,
than 130 ml on voiding cystourethrogram studies.                   maintaining pneumovesicum is difficult and we need
The patient is placed in the supine position with legs             some trocar tricks. In addition, small capacity blad-
apart. The bladder is filled with saline solution                  ders are difficult to navigate. Although this technique
through the urethra. Using an open technique or vi-                is extremely challenging, the visualization and con-
sualization via a flexible pediatric cystoscope, the 12            trol are excellent and we must continue to develop
mm camera port is placed in the midline at the blad-               this approach.
der dome. A 3-0 absorbable suture secures the blad-
der wall and skin to the trocar. The working ports,                Extravesical approach
either 8 or 5 mm, are positioned midway between the
umbilicus and pubis at the mid clavicular line. Ports              Surgical technique
are fixed to the abdominal wall using a stitch which               The extravesical approach can be performed unilater-
is also used to close the bladder. The bladder is filled           ally or bilaterally, following the same steps as the
with CO2 to drain the saline and the robotic device is             open Lich-Gregoir technique. Cystoscopy can be per-
brought over the patient’s feet. Similar to the open               formed to place open ended ureteral catheters to aid
technique, ureteral dissection starts after placement              in the dissection. With the patient in the supine posi-
of a 6 cm segment of a 5 Fr feeding tube or 4 Fr open              tion an open technique is used to place the first trocar,
ended ureteral catheter, secured to the ureter with a              the 12 mm camera port, in the umbilicus. The work-
4-0 absorbable suture. Mobilization of the ureters is              ing ports, 8 or 5 mm, are positioned in the mid clavic-
done as in the laparoscopic pneumovesical procedure                ular line bilaterally, about 1 cm below the umbilical
116                                                       P. Casale, Y. Kojima

                                                                      vic plexus is readily identified medial and caudal to
                                                                      the ureter. Care is taken in each case to identify the
                                                                      pelvic plexus, avoiding injury to the area and allow-
                                                                      ing ureteral mobilization at the hiatus. Approximately
                                                                      4–5 cm is dissected to permit mobility and to prevent
                                                                      kinking as the bladder tunnel is created for the ureter
                                                                      (Fig. 6). A hitch stitch through the posterior bladder
                                                                      wall can be used to improve the exposure of the ure-
                                                                      teral hiatus if the bladder is large. A detrusor trough
                                                                      is created by incising the muscularis of the bladder
                                                                      for about 3 cm and developing flaps with the cautery
                                                                      scissors. Any perforations of the mucosa are closed
                                                                      using a 5-0 absorbable suture prior to trough closure.
                                                                      The bladder muscularis is then closed over the ureter,
                                                                      using a 4-0 absorbable interrupted suture. Care must
                                                                      be taken to avoid any kinking or excessive compres-
                                                                      sion of the ureter to prevent obstruction. Closure is
                                                                      performed proximal to distal or vice versa. In the lat-
Fig. 6. Robotic-assisted laparoscopic ureteral reimplantation (ex-
travesical approach); creation of detrusor tunnel for extravesical    ter, the ureter is well visualized but the needle needs
ureteral reimplant.                                                   to be passed under the ureter each time the suture is
                                                                      placed. I catch the adventitia of the ureter with each
                                                                      suture to ensure it does not slip back during the heal-
                                                                      ing process. The urethral catheter is removed the next
                                                                      morning and the child is discharged after voiding.
                                                                      Open extravesical ureteral reimplantation was re-
                                                                      ported to be an effective method for repairing reflux
                                                                      without ureteral obstruction, but it can also result in
                                                                      a high rate of transient postoperative urinary reten-
                                                                      tion even when detrusor dissection is minimized (33).
                                                                      However, we reported that a total of 41 patients un-
                                                                      derwent robotic-assisted laparoscopic extravesical
                                                                      reimplantation for bilateral VUR with 97.6% of suc-
                                                                      cess rate and without complication including urinary
                                                                      retention or exacerbation of dysfunctional voiding
                                                                      (32). The improved visualization can avoid the injury
                                                                      of neurovasucular plexus, which is situated just lat-
                                                                      eral to the ureteral hiatus, and might decrease the
                                                                      incidence of postoperative urinary retention.

                                                                      Bladder outlet obstruction and dysfunction caused by
                                                                      neuropathic bladder, nonneurogenic bladder, poste-
                                                                      rior urethral valves and the exstrophy-epispadias
                                                                      complex, often lead to urinary incontinence and renal
                                                                      dysfunction in children. Although some of these chil-
Fig. 7. Robotic-assisted laparoscopic appendicovesicostomy; the
appendix is anastomosed to a small mucosal opening in the apex        dren can be treated medically or with minimally in-
of the detrusor trough.                                               vasive intervention, in most of them augmentation
                                                                      cystoplasty with a continent catheterizable channel,
                                                                      usually appendicovesicostomy is the standard of
line. If the child has a pubo-umbilical length less than
8 cm, then the midline camera port must be placed                     Surgical technique
above the umbilicus between the xyphoid and umbi-                     As the authors of the purely laparoscopic procedure,
licus to prevent robotic arm collision. The robotic is                we can honestly state that the procedure is extremely
docked over the patient’s feet. The technique follows                 facilitated with robotics. The patient is placed in the
the same steps as the Lich-Gregoir open procedure.                    supine position in Trendelenburg. Three ports are uti-
It starts by dissecting the ureter after opening the                  lized. The 12 mm camera port is placed in the umbi-
peritoneum anterior to the uterus and just over the                   licus; and the other two 8 mm working ports on the
posterior bladder wall. The ureter is freed from the                  right and left sides, in the mid clavicular line at the
surrounding tissue keeping its vessels intact. The pel-               level of the anterior superior iliac spines. The proce-
                              Robotic-assisted laparoscopic surgery in pediatric urology: an update                      117

dure commences with cecal mobilization. Care is                   ing ports, one on the same side of the testicle, above
taken to protect the appendiceal mesentery and mo-                the umbilicus in the mid clavicular line, and the other
bilize with an adequate length. Once the cecum is                 contralaterally below the umbilicus, also in the mid
mobilized, the appendix is separated from the cecum,              clavicular line.
leaving a small cuff of cecum with the appendix. The
bladder is filled with saline and after measuring the
best position for the appendix due to its length, mo-             Najmaldin and Antao performed bilateral orchi-
bility of the bladder, and location of the stoma. A 4             dopexy and the excision of Müllerian remnant using
cm detrusorrhaphy is made. The appendix is anasto-                robotic-system for a boy (43). Although available, we
mosed to a small mucosal opening in the apex of the               have not found the robot to be useful in orchiopexies
detrusor trough and the defect is closed using 4-0                since reconstruction is not part of the procedure.
absorbable interrupted suture (Fig. 7). The base of the
appendix is brought up to reach the umbilicus or the              OTHERS
right lower quandrant. I prefer the right lower quad-
rant trocar site to create a catheterizable stoma using           A variety of other procedures have been performed
a V flap technique.                                               using robotics in children such as pyelolithotomy
                                                                  (44), correction of retrocaval ureter (45), adrenalec-
Outcome                                                           tomy, bladder neck sling (46), ureteropyelostomy,
There are several case reports of a robotic-assisted              excision of Müllerian duct remnants (43), sacrocol-
Mitrofanoff procedure in a child (34–38), as well as              popexy just to name a few. In all cases, we could
one described purely laparoscopic (39). Pedraza et al             complete the procedure successfully in operative
reported the first case of an appendicovesicostomy                times comparable to open approaches. These various
performed entirely laparoscopically using robotic                 cases also indicate the potential flexibility of this sys-
system (34). Recently Gundeti et al. have reported                tem for varied case challenges, particularly in the
that robotic-assisted laparoscopic Mitrofanoff appen-             field of pediatric urology where a large variety of
dicovesicostomy and augmentation ileocystoplasty                  surgical procedures are needed in the care of our pa-
(35). Additionally, there are two cases of robot-as-              tients.
sisted laparoscopy for simultaneous reconstruction
of a continent urinary diversion using the Mitro-
fanoff principle and the antegrade continent enema
(36, 37).                                                         POSTOPERATIVE PAIN MANAGEMENT

                                                                  Postoperative pain management is always an area for
ORCHIOPEXY                                                        debate. Injection of the port sites does aid in postop-
Indication                                                        erative pain control. An anti inflammatory such as
                                                                  Ketorolac has also been beneficial to control pain in
Nonpalpable testis, which comprises about 20% of                  our experience. For all the patients undergoing ro-
undescended testes, may include testicular agenesis,              botic procedures at our institution, we utilize intra-
intraabdominal testicular nubbin, intraabdominal tes-             thecal opioid injection. We have found that there is
tis, vanishing testis, extraabdominal testicular nubbin           decreased length of stay and postoperative pain (47).
or intracanalicular testis, but is not palpable despite           There are no intravenous rescues in the first 24 hours
careful physical examination. Although the laparo-                postoperatively. Ketorolac is our drug of choice for
scopic procedure was originally performed for diag-               added pain management. On the other hand, Freilich
nostic purposes, it has become more feasible in pedi-             et al. have recently reported that the administration
atric patients with nonpalpable testis. It allows not             of intraperitoneal aerosolized bupivacaine just prior
only diagnosis, but also adequate therapy, and has                to incising the perirenal fascia appears to be a simple,
become the gold standard for managing nonpalpable                 effective and low-cost method to reduce postopera-
testis (40, 41). Once the testis has been identified in-          tive pain in children undergoing RAS (48).
traabdominally, laparoscopic orchiopexy or Fowler-
Stephens orchiopexy is generally indicated for in-
traabdominal testis (42).
Surgical technique
The advantages of laparoscopic orchiopexy for in-                 Reported series of RAS in pediatric urology are
traabdominal testis are the ability to start treatment            shown in Table 2. RAS enables a revolutionary ad-
as soon as a diagnosis is made and to permit MIS.                 vance for pediatric urological surgery and provides
Improving upon the same skill set described in con-               great benefit for patients and surgeons. It allows in
ventional laparoscopy, robotic surgery can be used in             situ surgery with unparalleled exposure better than
difficult cases such as high intra abdominal testicles,           what is seen with an open approach even when the
and in particular for second staged surgeries. The                incision is large. Robotic technology will certainly
patient is placed supine in the Trendelenburg posi-               evolve with or without us. We need to embrace it and
tion with the ipsilateral side elevated. We routinely             realize any limitations so we can shape it. For the
empty the bladder to aid in access and visualization.             safety and well being of our patients, we, ultimate
Port placement mimics conventional laparoscopy,                   users of such systems, must be actively involved in
with the camera port in the umbilicus, and two work-              their evolution.
118                                                                   P. Casale, Y. Kojima

                                                                             TABLE 2
                                      Robotic-assisted laparoscopic surgery in pediatric urology; reported series.

Procedures               Reference                  No.            (Mean/         Approach                (Mean/           (Mean/          No.     Success rate
                                                 procedures        median)                                median)          median)       Compli-
                                                                 Age* (range)                            Operative    Hospital stay¶                   (%)
                                                                                                       time** (range)   (range)

Heminephroureterectomy Pedraza et al.            1(bilateral)          4          Transperitoneal           440               2             0           –
(Partial nephrectomy)  Olsen et al. (2005)           14          4.9 (0.5–20.2)   Retroperitoneal      176 (120–360)     1.0 (1.0–4.0)      3           –
                       Lee et al. (2009) 11          09          7.2 (0.5–16.5)   Transperitoneal      275 (170–417)     2.9 (1.9–4.8)      2           –
Pyeloplasty              Atug et al. (2005) 15       07            13.0 (6–15)  Transperitoneal      184 (165–204)       1.2 (1.0–3.0)      1          100
                         Yee et al. (2006) 16        08         11.5 (6.4–15.6) Transperitoneal      363 (255–522)       2.4 (1.0–5.0)      1          100
                         Lee et al. (2006) 17        33          7.9 (0.2–19.6) Transperitoneal (32) 219 (133–401)       2.3 (0.5–6.0)      1          93.9
                                                                                Retroperitoneal (1)
                         Kutikov et al               09           0.5 (0.3–0.7) Transperitoneal           123                 1.4           0          100
                         Olsen et al. (2007)18       67          7.9 (1.7–17.1) Retroperitoneal         143 (93–300)     2.0 (1.0–6.0)     120         94
                         Franco et al. (2007)        15         11.9 (4.0–18.0) Transperitoneal        223 (150–290)     Not reported       4         Not
                         20                                                                                                                         reported
Ureterocalicostomy       Casale et al. (2008)        09           6.5 (3–15)      Transperitoneal      168 (102–204)     0.9 (0.7–1.1)      0          100
Ureteroureterostomy      Kutikov et al. (2007)       02           8.0 (6–10)      Transperitoneal       Not reported     Not reported       0          100
                         Passerotti et al.           03          9.5 (4.7–14.3)   Transperitoneal      244 (240–251)     3.5 (2.4–4.3)      0          100
                         (2008) 26
Pyelolithotomy           Lee et al. (2007) 44        05         16.6 (10.2–23.2) Transperitoneal       315 (165–465)     3.8 (2.3–5.7)      1           75
                                                                                                                                                   (stone free)
Ureteral reimplantation
  Vesicoscopic approach Peters et al. (2005)         06             (5–15)        Transvesical          Not reported         (2–4)          1          83.3
  Extravesical approach Casale et al. (2008)         41          3.20(1.3–6.8)    Transperitoneal      2.33 (1.4–3.19)   1.1 (0.8–1.4)      0          97.6
Appendicovesicostomy     Pedraza et al. (2004)       01               07          Transperitoneal           360               4             0           –
(+augmentation +         Gundeti S et al.            01               10          Transperitoneal           600               5             0           –
ileocystoplasty)         (2008) 35
(+ antegrade continent   Thakre et al. (2008)        01               10          Transperitoneal           200               5             0           –
enema procedures)        36
(+antegrade continent    Lendvay et al.              01               09          Transperitoneal           480               5             1           –
enema procedures)        (2008) 37
Bladder neck sling        Storm et al. (2008)        02          9.50(9.0–10.0)   Transperitoneal      189 (170–208)       3 (2–4)          0          100

* years old, ** ; minutes, ¶; days

  In conclusion, although further outcome studies                                     05. Yucel S, Brown B, Bush NC et al: What to anticipate with ex-
and more prospective randomized comparison                                                perience in pediatric laparoscopic ablative renal surgery. J Urol
studies with open surgery or conventional laparo-                                     06. Basiri A, Simforoosh N, Heidari M et al: Laparoscopic v open
scopic surgery may be needed, almost all operations                                       donor nephrectomy for pediatric kidney recipients: prelimi-
that are classically performed as open or conventional                                    nary report of a randomized controlled trial. J Endourol 2007;
laparoscopic reconstructive surgery for children with                                     21:1033–1036
                                                                                      07. Cervellione RM, Gordon M, Hennayake S: Financial analysis
urological anomalies could be replaced by RAS which                                       of laparoscopic versus open nephrectomy in the pediatric age
may be established as an alternative MIS in the fu-                                       group. J Laparoendosc Adv Surg Tech A 2007;17:690–692
ture.                                                                                 08. Peters CA: Laparoscopy in pediatric urology. Curr Opin Urol
                                                                                      09. Koyle MA, Woo HH, Kavoussi LR. Laparoscopic nephrectomy
REFERENCES                                                                                in the first year of life. J Pediatr Surg 1993; 28:693–695
                                                                                      10. Harrell WB, Snow BW. Minimally invasive pediatric nephrec-
1. McCullough TC, Barret E, Cathelineau X et al: Role of robotics                         tomy. Curr Opin Urol. 2005;15:277–281
   for prostate cancer. Curr Opin Urol 2009;19(1):65–68                               11. Lee RS, Sethi AS, Passerotti CC et al. Robot assisted laparo-
2. Peters C: Laparoscopy in pediatric urology: adoption of innova-                        scopic partial nephrectomy: a viable and safe option in chil-
   tive technology. BJU Int 2003;92(Suppl 1):52–57                                        dren. J Urol 2009;181:823–828
3. Peters CA: Robotic assisted surgery in pediatric urology. Pedi-                    12. Pedraza R, Palmer L, Moss V, Franco I. Bilateral robotic as-
   atr Endosurgery Innovative Tech 2003;7:403–413                                         sisted laparoscopic heminephroureterectomy. J Urol 2004;171:
4. Peters CA: Robotically assisted surgery in pediatric urology.                          2394–2395
   Urol Clin North Am 2004;31:743–752                                                 13. Olsen LH, Jørgensen TM. Robotically assisted retroperitoneo-
                                       Robotic-assisted laparoscopic surgery in pediatric urology: an update                               119

      scopic heminephrectomy in children: initial clinical results.        31. Peters CA, Woo R: Intravesical robotically assisted bilateral
      J Pediatr Urol 2005;1:1440–1442                                          ureteral reimplantation. J Endourol 2005;19:618–621
14.   Olsen LH, Jorgensen TM. Computer assisted pyeloplasty in             32. Casale P, Patel RP, Kolon TF: Nerve sparing robotic extravesi-
      children: the retroperitoneal approach. J Urol 2004;171:2629–            cal ureteral reimplantation. J Urol 2008;179:1987–1989
      2631                                                                 33. Lipski BA, Mitchell ME, Burns MW: Voiding dysfunction after
15.   Atug F, Woods M, Burgess SV, Castle EP, Thomas R. Robotic                bilateral extravesical ureteral reimplantation. J Urol 1998;159:
      assisted laparoscopic pyeloplasty in children. J Urol 2005;174:          1019–1021
      1440–2                                                               34. Pedraza R, Weiser A, Franco I: Laparoscopic appendicovesi-
16.   Yee DS, Shanberg AM, Duel BP et al. Initial comparison of                costomy (Mitrofanoff procedure) in a child using the daVinci
      robotic-assisted laparoscopic versus open pyeloplasty in chil-           robotic system. J Urol 2004;171:1652–1653
      dren. Urology 2006; 67: 599–602                                      35. Gundeti MS, Eng MK, Reynolds WS, Zagaja GP: Pediatric ro-
17.   Lee RS, Retik AB, Borer JG, Peters CA. Pediatric robot assisted          botic-assisted laparoscopic augmentation ileocystoplasty and
      laparoscopic dismembered pyeloplasty: comparison with a                  Mitrofanoff appendicovesicostomy: complete intracorporeal
      cohort of open surgery. J Urol 2006;175:683–687                          – initial case report. Urology 2008;72:1144–1147
18.   Olsen LH, Rawashdeh YF, Jorgensen TM. Pediatric robot as-            36. Thakre AA, Yeung CK, Peters C: Robot-assisted Mitrofanoff
      sisted retroperitoneoscopic pyeloplasty: a 5-year experience.            and Malone antegrade continence enema reconstruction using
      J Urol 2007;178:2137–2141                                                divided appendix. J Endourol 2008;22:2393–2396
19.   Kutikov A, Nguyen M, Guzzo T, Canter D, Casale P. Robot              37. Lendvay TS, Shnorhavorian M, Grady RW: Robotic-assisted
      assisted pyeloplasty in the infant-lessons learned. J Urol 2006;         laparoscopic Mitrofanoff appendicovesicostomy and antegrade
      176:2237–2239                                                            continent enema colon tube creation in a pediatric spina bifida
20.   Franco I, Dyer LL, Zelkovic P. Laparoscopic pyeloplasty in the           patient. J Laparoendosc Adv Surg Tech A 2008;18:310–312
      pediatric patient: hand sewn anastomosis versus robotic as-          38. Storm DW, Fulmer BR, Sumfest JM: Laparoscopic robot-as-
      sisted anastomosis – is there a difference? J Urol 2007;178:1483–        sisted appendicovesicostomy: an initial experience. J Endourol
      1486                                                                     2007;21:1015–1017
21.   Thakre AA, Bailly Y, Sun LW, Van Meer F, Yeung CK: Is smaller        39. Casale P, Feng WC, Grady RW et al: Intracorporeal laparo-
      workspace a limitation for robot performance in laparoscopy?             scopic appendicovesicostomy: a case report of a novel ap-
      J Urol 2008;179:1138–1142                                                proach. J Urol 2004; 171:1899–1900
22.   Passerotti CC, Nguyen HT, Eisner BH, Lee RS, Peters CA:              40. Radmayr C, Oswald J, Schwentner C et al: Long-term outcome
      Laparoscopic reoperative pediatric pyeloplasty with robotic              of laparoscopically managed nonpalpable testes. J Urol 2003;
      assistance. J Endourol 2007; 21:1137–1140                                170:2409–2411
23.   Hemal AK, Mishra S, Mukherjee S: Suryavanshi M. Robot as-            41. Gatti JM and Ostlie DJ: The use of laparoscopy in the manage-
      sisted laparoscopic pyeloplasty in patients of ureteropelvic             ment of nonpalpable undescended testes. Curr Opin Pediatr
      junction obstruction with previously failed open surgical re-            2007;19:349–353
      pair. Int J Urol 2008;15:744–746                                     42. Casale P, Canning DA. Laparoscopic orchiopexy. BJU Int
24.   Casale P, Mucksavage P, Resnick M, Kim SS: Robotic uretero-              2007;100:1197–1206
      calicostomy in the pediatric population. J Urol. 2008;180:2643–      43. Najmaldin A, Antao B. Early experience of tele-robotic surgery
      2648                                                                     in children. Int J Med Robot 2007;3:199–202
25.   Kutikov A, Nguyen M, Guzzo T, Canter D, Casale P: Laparo-            44. Lee RS, Passerotti CC, Cendron M et al: Early results of robot
      scopic and robotic complex upper tract reconstruction in the             assisted laparoscopic lithotomy in adolescents. J Urol 2007;177:
      child with duplex collecting system. J Endourol 2007; 21: 619–           2306–2309
      622                                                                  45. Gundeti MS, Duffy PG, Mushtaq I: Robotic-assisted laparo-
26.   Passerotti CC, Diamond DA, Borer JG et al: Robot-assisted                scopic correction of pediatric retrocaval ureter. J Laparoendosc
      laparoscopic ureteroureterostomy: description of technique.              Adv Surg Tech A 2006;16:422–424
      J Endourol 2008;22:581–584                                           46. Storm DW, Fulmer BR, Sumfest JM: Robotic-assisted laparo-
27.   Yeung CK, Sihoe JD, Borzi PA: Endoscopic cross-trigonal ure-             scopic approach for posterior bladder neck dissection and
      teral reimplantation under carbon dioxide bladder insuffla-              placement of pediatric bladder neck sling: initial experience.
      tion: a novel technique. J Endourol 2005;19:295–299                      Urology 2008;72:1149–1152
28.   Hayn MH, Smaldone MC, Ost MC, Docimo SG: Minimally                   47. Ganesh A, Kim A, Casale P, Cucchiaro G: Low-dose intrathecal
      invasive treatment of vesicoureteral reflux. Urol Clin North             morphine for postoperative analgesia in children. Anesth An-
      Am 2008;35:477–488                                                       alg 2007;104:271–276
29.   Lendvay T: Robotic-assisted laparoscopic management of vesi-         48. Freilich DA, Houck CS, Meier PM et al: The effectiveness of
      coureteral reflux. Adv Urol 2008:732942                                  aerosolized intraperitoneal bupivacaine in reducing post-
30.   Olsen LH, Deding D, Yeung CK, Jorgensen TM: Computer                     operative pain in children undergoing robotic-assisted laparo-
      assisted laparoscopic pneumovesical ureter reimplantation                scopic pyeloplasty. J Pediatr Urol 2008;4:337–340
      a.m. Cohen: initial experience in a pig model. APMIS 2003;
      109:23–25                                                            Received: February 24, 2009

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