What are the guidelines for pediatric robotic urological surgeries?

Guidelines for Pediatric Robotic Urological Surgeries

Robot-assisted laparoscopic surgery in pediatric urology should be offered as an alternative treatment option only in centers with established experience, as it cannot be recommended as a routine procedure at present. 1

Current Status and Indications

• Robot-assisted laparoscopic ureteral reimplantation (RALUR) is considered a feasible and effective surgical approach for primary pediatric vesicoureteral reflux (VUR), with success rates similar to open ureteral reimplantation (OUR) 1
• Robotic pyeloplasty has demonstrated excellent outcomes with success rates of up to 100% in specialized centers 2
• Common pediatric urological procedures performed robotically include pyeloplasty, ureteral reimplantation, partial nephrectomy, nephroureterectomy, appendico-vesicostomy, augmentation cystoplasty, and bladder neck reconstruction 3
• The extravesical approach is most commonly used for robotic antireflux surgeries 1

Advantages and Limitations

• Robotic technology provides enhanced three-dimensional vision, increased instrument dexterity, and tremor filtration, which are particularly beneficial in the limited operational field of pediatric patients 4, 5
• Compared to open surgery, robot-assisted procedures show lower postoperative pain and shorter hospital stays 1
• Limitations include higher operative times, costs, and rates of postoperative complications requiring secondary intervention compared to open procedures 1
• De novo hydronephrosis can occur in up to 30% of cases after extravesical RALUR, similar to open ureteral reimplantation, but is self-resolving in most cases 1

Patient Selection Guidelines

• RALUR is generally preferred for unilateral low-grade VUR cases 1
• Older children with complex anatomy and/or following failed injection or open reimplantation may particularly benefit from RALUR 1
• Caution is advised in bilateral cases due to the risk of transient urinary retention 1
• For robotic pyeloplasty, patient selection should consider the size of the child, with newer single-port techniques requiring adaptation for smaller pediatric patients 6

Training and Credentialing Requirements

• The first 3-5 cases of a novice urologist should be proctored by an approved proctor, preferably the same one for all cases 1
• Individual requirements may vary based on the surgeon's prior experience with laparoscopic vs. open procedures 1
• Informed consent must be obtained from patients/parents regarding the role of the proctor during surgery 1
• Institutions should establish a robotic committee for periodic review of surgeon performance, including case selection, surgical competence, complication management, and postoperative outcomes 1

Technical Considerations

• During COVID-19 pandemic, specific precautions were recommended for robotic procedures, including:
  • Lower electrocautery power settings to generate less smoke
  • Keeping intraperitoneal pressure as low as possible
  • Using integrated active smoke evacuation systems
  • Limiting operating room staff to essential personnel 1
• For single-port robotic pyeloplasty, technique refinements include concealed incision placement, optimal positioning for robotic docking, and maintaining adequate distance from target anatomy in smaller patients 6

Safety and Outcome Monitoring

• A system of periodic review by the institutional robotic committee should evaluate surgeon performance, including case selection, surgical competence, complication management, and postoperative outcomes 1
• Continuation of robotic privileges should depend on consistent performance across these criteria 1
• Failure to perform adequately should result in recommendations for refresher training or additional preceptoring 1

Future Directions

• Development of smaller instruments more suitable for pediatric use is needed 5
• Integration of technologies such as indocyanine green fluorescence imaging may improve visualization of vascular anatomy 5
• Wider adoption will depend on introduction of new robotic platforms that may lower costs 5
• Larger case series and prospective randomized controlled trials are necessary to validate reported outcomes 3

Common Pitfalls and Caveats

• The learning curve for robotic procedures is steep and can impact outcomes, particularly in the early phase 1
• Robotic approaches are more invasive than endoscopic correction for conditions like VUR 1
• Potential advantages over open surgery continue to be analyzed and are not yet fully established 1
• Cost-effectiveness remains a significant concern and requires further validation 4, 5