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Year : 2023  |  Volume : 39  |  Issue : 2  |  Page : 107-120

Pediatric robotic urologic procedures: Indications and outcomes

1 Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
2 Pritzker School of Medicine, University of Chicago; Department of Surgery, Section of Urology, University of Chicago, Comer Children's Hospital, Chicago, IL, USA

Date of Submission02-Aug-2022
Date of Decision10-Dec-2022
Date of Acceptance09-Mar-2023
Date of Web Publication31-Mar-2023

Correspondence Address:
Mohan S Gundeti
Pritzker School of Medicine, University of Chicago; Department of Surgery, Section of Urology, University of Chicago, Comer Children's Hospital, Chicago, IL
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/iju.iju_276_22

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Introduction: Robotic-assisted laparoscopic surgery (RALS) has revolutionized minimally invasive surgery in pediatric urology. The robotic platform allows surgeons to maintain the benefits of laparoscopic surgery while having enhanced three-dimensional view, dexterity, range of motion, and control of high-resolution cameras. In this review, we summarize the indications and recent outcomes for various pediatric urologic RALS procedures to illustrate the current state of robotics in pediatric urology.
Methods: We systematically searched the PubMed and EMBASE databases. We extrapolated and summarized recent evidence on RALS in pediatric urology patients, with an emphasis on indications and outcomes, with regard to the following procedures and search terms: pyeloplasty, kidney stone surgery, partial nephrectomy, nephroureterectomy, ureteral reimplantation, appendico-vesicostomy, augmentation cystoplasty, bladder neck reconstruction, and Malone antegrade continence enema. Additional Medical Subject Headings terms used to augment the search included “Treatment Outcome” and “Robotic Surgical Procedures.”
Results: Increasing usage of RALS has shown many benefits in perioperative and postoperative outcomes. In addition, there is growing evidence that robotic procedures in pediatric urology result in similar or better surgical outcomes when compared to the standard of care.
Conclusions: RALS has shown considerable effectiveness in pediatric urologic procedures and may achieve surgical outcomes comparable to the standard approaches of open or laparoscopic surgery. However, larger case series and prospective randomized controlled trials are still necessary to validate the reported outcomes, in addition to cost analyses and studies on the surgical learning curve. We believe that the continuous evolution of robotic platforms will allow for enhanced care and quality of life for pediatric urology patients.

How to cite this article:
Hou SW, Xing MH, Gundeti MS. Pediatric robotic urologic procedures: Indications and outcomes. Indian J Urol 2023;39:107-20

How to cite this URL:
Hou SW, Xing MH, Gundeti MS. Pediatric robotic urologic procedures: Indications and outcomes. Indian J Urol [serial online] 2023 [cited 2023 May 30];39:107-20. Available from:

   Introduction Top

The introduction and advancement of robotic-assisted surgical systems have revolutionized minimally invasive surgery in pediatric urology. By utilizing this surgical platform, surgeons maintain the benefits of laparoscopic surgery while having the additional advantages of added dexterity, greater range of movement, enhanced three-dimensional visualization, and increased control of high-resolution cameras.[1] With the advancement of robotic-assisted laparoscopic surgery (RALS), minimally invasive techniques for urologic surgeries have evolved greatly over the past couple of decades, especially in the United States and parts of Europe.

Moreover, RALS has been adopted and optimized for pediatric urologic patients in recent years.[2] The advantages of RALS make this technology ideal for children who require major reconstructive procedures, as this system is able to generate fine movements in limited working spaces. Since the initial implementation of RALS for pyeloplasty in pediatric patients, several robotic procedures, including complex reconstructive cases, have been established in the practice of pediatric urologists. This has yielded a growing body of literature on favorable perioperative and postoperative outcomes and patient satisfaction compared with traditional surgical approaches.

In this review, we summarize the indications and outcomes for various pediatric urologic RALS procedures to illustrate the current state of robotics in pediatric urology with a focus on the recent advances in literature.

   Methods Top

A systematic search of the PubMed and EMBASE databases was performed. Recent evidence on indications and outcomes for RALS in pediatric urology patients was extrapolated and summarized for the following procedures: pyeloplasty, kidney stone surgery, partial nephrectomy and nephroureterectomy, ureteral reimplantation, appendico-vesicostomy, augmentation cystoplasty, bladder neck reconstruction (BNR), and Malone antegrade continence enema (MACE). Additional Medical Subject Headings terms used to augment the search included “Treatment Outcome” and “Robotic Surgical Procedures.”

   Pyeloplasty Top

The gold standard for surgical treatment of ureteropelvic junction obstructions (UPJOs) is open pyeloplasty, but laparoscopic pyeloplasty has been widely accepted since the 1990s and has become the preferred surgical approach.[2],[3] Even more recently, robotic-assisted laparoscopic pyeloplasty has garnered significant attention since 2005.

Early retrospective studies within the first 10 years of introducing RALP demonstrated the procedure's safety and feasibility in pediatric patients [Table 1]. While studies showed longer operative times for RALP, durations decreased with surgeon experience.[4] A meta-analysis by Cundy et al. analyzing 12 studies comparing RALP to open or laparoscopic pyeloplasty reported that RALP may offer shorter length of stay (LOS), lower estimated blood loss, and lower analgesic dosing at the expense of higher operating cost and longer operating time.[5] More recent studies from the past 5 years have continued to show that RALP is comparable to the alternative approaches [Table 1], and has been suggested by some groups as a universal approach for pediatric patients with UPJO.[6]
Table 1: Summary of pyeloplasty primary outcomes

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RALP in infants has been less well studied. Infant RALP is comparable to both open and laparoscopic pyeloplasty [Table 1].[7],[8] Andolfi et al. followed 44 infants who underwent RALP for UPJO and found that at a median follow-up of 19 months, the success rate was 100%.[9] To date, the largest study of infant RALP included 60 subjects and found a 91% success rate in reducing hydronephrosis.[10] Further studies have considered the impact of age and weight on RALP patient outcomes, finding no significant disadvantage in younger or lighter patients.[11],[12]

Current literature demonstrates that RALP operative time decreases with surgical experience, with operative time decreasing after 15–41 cases.[13],[14],[15] Operative times have been estimated to decrease by approximately 4 min per case until a plateau is reached.[13] Previous experience in open or laparoscopic pyeloplasty may streamline the learning curve.[16] Interestingly, in a recent study on the learning curve of infant RALP, Andolfi et al. reported that a plateau in operating time is achieved after 13 cases, followed by additional improvement at 37 cases.[17]

As RALP continues to gain popularity, careful cost analysis are needed to aid institutions in considering the adoption of such an expensive technology. Studies have found that RALP can be $1060–$4000 more expensive than open pyeloplasties when considering the patient's operative and postoperative course.[18] The major cost contributors in the setting of pediatric pyeloplasties are operating room (OR) use, equipment costs, and room and board.[18],[19] While RALP has major advantages in room and costs related to stay in hospital, expenses for OR use and equipment are significantly higher than open pyeloplasties. Of note, these studies may also not consider personnel training, maintenance, and initial costs to setup new equipment. Thus, RALP may only be cost-effective in high-volume experienced surgical centers.

   Kidney Stone Surgery Top

Rates of nephrolithiasis in the pediatric population have risen over the last decade, with an estimated increase of 4%–10% annually in the United States.[20] According to the American Urological Association and Endourological Society Guidelines, ureteroscopy, retrograde intrarenal surgery, and extracorporeal shock wave lithotripsy (ESWL) are considered for smaller stones, whereas ESWL, and percutaneous nephrolithotomy are standard for larger stones.[21],[22] While RALS is not standard treatment, such interventions remain options for patients with more complex diseases.[22]

Robotic removal of kidney stones has been studied in the adult population, but literature remains scarce for the pediatric cohort.[2] As of 2019, there was only one study dedicated to RALS of stone disease in children.[22] Since then, only a handful of studies and case reports on robotic-assisted nephrolithotomies have been published.[23],[24],[25],[26] Roth et al. conducted a multi-institutional retrospective review of 26 children who underwent endoscopic-assisted robotic pyelolithotomy (EARP).[23] Overall stone-free status was approximately 70% and rose to 96.3% after secondary treatment. The authors concluded that in select individuals with concomitant UPJO or altered anatomy, the EARP technique is viable and results in low complication rates and high stone-free rates. Similarly, in an international multi-center retrospective study of 15 children, the authors concluded that in select patients, robotic-assisted stone removal is feasible, effective, and safe.[24] Studies with larger populations and longer follow-up will help to elucidate the role of RALS in stone management.

   Partial Nephrectomy and Nephroureterectomy Top

Partial nephrectomies and nephroureterectomies may be indicated for patients with anatomic kidney anomalies with nonfunctioning moiety or segment such as horseshoe or duplex kidney, as well as patients with kidney tumors.[27] While robotic-assisted laparoscopic partial nephrectomy (RALPN) is widely accepted in the adult population, Lee et al. were the first to report the feasibility and safety of RALPN in a cohort of nine pediatric patients who presented with functional and anatomical malformations of the kidney.[27] Since this initial study, larger studies on RALPN in the setting of pediatric duplex kidneys have been published [Table 2].
Table 2: Summary of partial nephrectomy primary outcomes

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Comparative studies have also been completed on RALPN versus open partial nephrectomy and laparoscopic partial nephrectomy.[28],[29] Studies have found that while patients who undergo open partial nephrectomy have significantly shorter operative times, they also experience significantly larger volumes of blood loss, longer postoperative hospital stays, and higher morphine and acetaminophen intake than those who undergo more minimally invasive procedures.[28],[29]

The utilization of RALPN in the setting of pediatric malignant renal tumors is also being investigated in its early stages. Blanc et al. reported the initial results of utilizing RALPN and RALN in ten pediatric patients (nine with Wilms' tumor and one with renal sarcoma) at a high-volume pediatric care center.[30] Three of ten cases were converted to open technique, complete removal of the tumor without rupture was achieved in all cases, and all patients had an uneventful postoperative course. Compared to the open surgery cohort, there was no difference in operative time, but the median tumor volume was smaller and hospital stay was shorter.

Nephroureterectomy is a procedure similar to partial nephrectomy, but with the additional removal of the ureter. To date, there is only one study on the outcomes of pediatric robotic-assisted laparoscopic nephroureterectomy (RALNU).[31] Bansal et al. compared RALNU to laparoendoscopic single-site nephroureterectomy in 32 pediatric patients and reported that RALNU had longer operative times but comparable postoperative narcotics use.[31] However, this study was limited by a small sample size and a single surgeon's experience.

In the past 3 years, there has been increasing research interest in RALPN with promising results. While this procedure has been deemed safe and feasible, additional research can help further elucidate the settings and patients for maximum benefit.

   Ureteral Reimplantation Top

Vesicoureteral reflux (VUR), which involves the retrograde flow of urine from the bladder into the ureters and kidneys, is the most common uropathy in children and occurs in approximately 1% of the pediatric population.[32] For patients with breakthrough urinary tract infections while on antibiotics or worsening VUR, open ureteral reimplantation has been the gold standard for surgical management. However, within the last decade, the prevalence of robot-assisted laparoscopic ureteral reimplantation (RALUR) has been on the rise.[2]

In 2011, Smith et al. published a retrospective comparative study of patients who underwent extravesical RALUR versus those who underwent open cross-trigonal ureteral reimplantation by a single surgeon.[33] Although the mean operative time was 12% longer in the robotic group, the mean LOS and pain medication usage was significantly less in the robotic group. The overall success rate, defined as no radiographic or clinical evidence of residual reflux, was 97% for the robotic group and 100% for the open group after a mean follow-up of 16 months. Marchini et al. published a retrospective case-matched comparative study of children who underwent either intravesical or extravesical RALUR or open ureteral reimplantation.[34] They found that the intravesical RALUR group had a shorter LOS, fewer bladder spasms, and a shorter duration of urinary catheter drainage compared to those who underwent intravesical open ureteral reimplantation. There was no difference in outcomes between the extravesical open and robotic-assisted groups. Moreover, the overall success rates were similar between RALUR and open reimplantation. However, due to higher complication rates and space constraints, the intravesical approach is not commonly used now. Many additional case series of pediatric RALUR have been reported with favorable outcomes [Table 3].
Table 3: Summary of ureteral reimplantation primary outcomes

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With the literature reporting increasing cases of the extravesical approach for RALUR (RALUR-EV), Gundeti et al. performed a retrospective study of RALUR-EV outcomes to standardize technique modifications to improve VUR resolution.[35] They standardized the technique of RALUR-EV, which was termed LUAA to represent the length of detrusor tunnel (L), use of a U stitch (U), placement of permanent ureteral alignment suture (A), and inclusion of ureteral adventitia (A) in detrusorraphy. Due to complications reported with the intravesical approach, RALUR-EV remains more common in practice.[36] A meta-analysis published in 2020 found that laparoscopic extravesical ureteric reimplantation had shorter operating time, higher success, and shorter hospital stay compared to trans-vesicoscopic ureteral reimplantation, along with comparable overall complication rates.[37]

In 2017, Boysen et al. published a multi-institutional retrospective study of outcomes and complications of RALUR-EV for the treatment of primary VUR in children.[38] In a cohort of 260 patients (363 ureters) from nine academic centers from 2005 to 2014, there were 25 complications overall (9.6%) with seven Grade III complications (2.7%) and no Grade IV or V complications. Radiographic resolution of VUR was seen in 246 of 280 ureters (87.9%) studied with postoperative voiding cystourethrogram or radionuclide cystogram. Boysen et al. followed this study with a prospective multicenter study of RALUR-EV outcomes in children, in which they found a radiographic success rate of 93.8% overall and 94.1% among children with grades III–V VUR.[39] Among a total of 199 ureters in 143 patients, ureteral complications occurred in five ureters (2.5%), and transient urinary retention occurred in four patients (7.1%) following the bilateral procedure and in no patients after the unilateral procedure. Furthermore, Esposito et al. published a systematic review of RALUR for pediatric VUR and showed that among 22 studies from 2008 to 2019 containing a total of 1362 children, the overall patient success rate was 92%.[40] The mean postoperative complication rate was 10.7% and the mean reoperation rate was 3.9%.

Interestingly, in 2019, Neheman et al. published a retrospective study of 27 pediatric patients who underwent RALUR-EV as an outpatient procedure, which reported promising results.[41] While additional studies on RALUR as an outpatient procedure are needed to assess its long-term outcomes with larger sample sizes, this innovative care pathway could eventually transform the current landscape of this procedure. With the possibility of performing RALUR as an outpatient procedure, we can potentially cater to the care of children by providing the potential option for them to recover in a comfortable and familiar environment.

There is robust evidence showing safe and effective outcomes in addition to other benefits with RALUR in pediatric patients, which raises the question of whether open ureteral reimplantation will remain the gold standard.[42] However, there is still debate over the cost of robotic surgeries. Kurtz et al. published a cost and complication comparison of robotic versus open pediatric ureteral reimplantation and reported higher median operative times, incidence of any 90-day complications and median hospital cost for RALUR ($9128 vs. $7273) compared to open ureteral reimplantation.[43] However, it is important to note that the timeframe of this study (2003–2013) was during the learning phase of RALUR for surgeons. Given that the cohort consisted of 1494 open cases and 108 robotic cases in addition to variable experience and reporting bias among different centers, further studies on financial outcomes are necessary.

   Appendicovesicostomy Top

Appendicovesicostomy (APV), also known as a Mitrofanoff procedure, allows for effective emptying of the bladder to maintain continence in patients that are unable or unwilling to perform urethral catheterization. Using the appendix to provide an alternate conduit to the bladder from an abdominal stoma, APV allows for patients to perform clean intermittent catheterization (CIC). While Mitrofanoff APV has traditionally been performed in an open approach, there is a growing body of literature supporting robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy (RALMA).

Several case reports or small case series on RALMA have been published since its initial report in 2004 [Table 4]. In 2016, Gundeti et al. published a multi-center study of 88 pediatric patients who underwent RALMA at five different institutions.[44] They reported favorable functional outcomes, with 85.2% of patients initially continent and 92.0% of patients continent at the last follow-up after additional procedures. Moreover, at 90 days' postoperation, 29.5% of patients had complications with 6.8% of patients being Clavien Grade III or higher. Given that these continence rates were comparable to outcomes of open series, they demonstrated that RALMA was safe and effective in their larger pediatric cohort.
Table 4: Summary of appendicovesicostomy primary outcomes

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In 2015, Grimsby et al. published a retrospective study comparing 28 open and 39 robotic APV outcomes.[45] They reported no differences in the number of complications and reoperations between the open and robotic groups at a mean follow-up of 2.7 years. While the time to reoperation was shorter in the robotic cohort, there was no difference in the number of patients who underwent reoperation within the first 12 months postoperatively between groups. In 2021, Galansky et al. published a retrospective large single-center study looking at 69 patients who underwent construction of continent catheterizable channels, which included APV, Monti with tapered ileum, and antegrade colonic enema (ACE).[46] Consistent with previously published literature, they reported similar continence rates between open and robotic approaches in addition to nonsignificant differences in the number of Clavien–Dindo grade postoperative complications. Surprisingly, while previous literature typically reported comparable LOS between robotic and open groups, they found significantly decreased LOS in the robotic cohort which was almost half of that of the open group (6.8 days vs. 12.6 days). The most up-to-date systematic review and meta-analysis by Juul et al. published in 2022, found comparable overall postoperative complication, surgical reintervention, stomal stenosis, and stomal continence rates between groups.[47] They reported shortened postoperative LOS in the robotic group among the studies included in their meta-analysis along with their own study cohort.

Overall, there is robust literature showing that RALMA is as safe and effective as the conventional open approach with the additional benefit of decreased postoperative LOS, suggesting that the robotic approach may soon be the future of this complex reconstructive procedure. Further studies comparing the costs and learning curve of robotic versus open APV are needed.

   Augmentation Cystoplasty Top

Augmentation cystoplasty is indicated in the management of patients with bladder voiding dysfunction, which is characterized by reduced bladder capacity and/or decreased compliance associated with high-pressure voiding refractory to conservative treatment.[48] This impaired bladder function is often secondary to different underlying conditions, including neurogenic bladder (commonly from spina bifida), nonneurogenic voiding dysfunctions, or rare congenital anatomic anomalies (e.g. exstrophy-epispadias complex and cloacal malformations). The ileum is the most common segment of the gastrointestinal tract that is utilized for cystoplasty, and this procedure is known as ileocystoplasty.[49] Open augmentation ileocystoplasty (OAI) remains the gold standard for bladder augmentation; however, open surgery is known to be associated with longer hospital stays, increased surgical scarring, and longer periods of postoperative pain.[2],[49]

In 2008, Gundeti et al. reported their first successful robotic-assisted laparoscopic augmentation ileocystoplasty (RALI) and Mitrofanoff APV, termed RALIMA, in a pediatric patient.[50] Since then, the usage of robotic assistance for augmentation ileocystoplasty has expanded in select medical centers, leading to studies with larger patient cohorts that highlight longer term perioperative and postoperative outcomes. In 2015, Murthy et al. published a study comparing 17 patients undergoing RALI and 13 patients undergoing OAI by a single surgeon.[51] They reported that the median operative time was significantly longer in RALI (623 min) compared to OAI (287 min) while the median LOS was shorter in RALI (6 days) compared to OAI (8 days). Of note, RALI resulted in similar functional outcomes as OAI, as the postoperative complication rates, percentage increase in bladder capacity, and narcotic use did not differ between cohorts. In 2016, Cohen et al. reported on the outcomes of patients undergoing RALI or OAI by two surgeons at two centers.[52] They reported similar functional outcomes between RALI and OAI approaches using matched controls, with longer operative times in the RALI cohort compared with OAI.

Together, these studies demonstrate the similar safety and efficacy of RALI compared with OAI, making it a feasible approach that may offer the benefits of reducing postoperative LOS in addition to offering cosmetic advantages.[2],[53] However, given the limited literature on pediatric patients, further investigation of longer term outcomes is necessary. With the continuous growth and usage of robotic technology in pediatric urology, the learning curve of this complex procedure will undoubtedly lessen, which will help reduce the longer operating times associated with the robotic approach.

   Bladder Neck Reconstruction Top

Bladder neck incompetence can lead to urinary incontinence and often stems from neurogenic bladder that is secondary to myelodysplasia, sacral agenesis, or other congenital lesions affecting the spinal cord. BNR is indicated in patients with an incompetent urethral sphincter to prevent incontinence.[54] Similar to other reconstructive procedures, BNR has traditionally been performed with an open approach. However, with the growing use of minimally invasive surgical techniques, there have been increasing but still limited reports of robotic-assisted BNR.

One of the first reports of robotic-assisted BNR was by Bagrodia and Gargollo in 2011 [Table 5].[55] Four patients with neurogenic bladder and sphincteric incompetence underwent robot-assisted BNR, bladder neck sling, and Mitrofanoff APV. Although one of the four patients required conversion to open surgery, all patients were completely dry on CIC postoperatively. Years later, Gargollo reported on the outcomes of 38 patients who underwent robot-assisted BNR and APV at their institution.[56] Thirty-one patients (82%) were completely dry during the day on CIC, while four of the seven patients who were wet were noncompliant with CIC. Other postoperative complications included de novo reflux in four patients and bladder stones in two patients.
Table 5: Summary of bladder neck reconstruction primary outcomes

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In 2016, Grimsby et al. published a retrospective study of perioperative and short-term outcomes in 45 patients who underwent either robotic-assisted or open BNR.[57] They reported no difference in preoperative urodynamics, age at surgery, or LOS, but operative time was significantly longer in the robotic group (8.2 h) versus the open group (4.5 h). Notably, there was no difference in complication rates within 30 days of surgery and the number of subsequent procedures for incontinence between the groups. More recently, Gargollo and White published a comprehensive literature review on robotic-assisted bladder neck procedures and compared them to a published series of open bladder neck procedures.[58] While they found that robotic-assisted approaches are associated with longer operative times, there was evidence that there are many potential benefits such as decreased blood loss and improved cosmesis along with equivalent continence rates as open procedures.

Although there is very limited literature on robotic-assisted BNR outcomes, the initial reports allow us to speculate that robotic BNR appears safe and results in similar outcomes to open BNR. Further comparative studies are necessary to substantiate whether the robotic approach is truly as safe and effective as the traditional open approach.

   Malone Antegrade Continence Enema Top

MACE, also known as appendicostomy, involves using the appendix and/or cecum to create a continent channel from the skin to the proximal colon to allow for enema administration in patients with bowel dysfunction.[59] This technique can be used to achieve fecal continence in patients with neurogenic bowel, which may stem from conditions such as spinal cord injury, spina bifida, tethered cord, cerebral palsy, or sacral agenesis. Since patients with neurogenic bowel disorders frequently co-present with neurogenic bladder, the construction of MACE and APV catheterizable channels serve as viable treatment options to achieve social continence. While MACE is also traditionally performed in an open approach, there has been a steady expansion of the application of laparoscopic or robotic-assisted minimally invasive surgery for this complex reconstruction.

After the initial reports of robotic MACE in pediatric patients in 2008, additional case reports and small case series have been reported [Table 6]. Galansky et al. reported on the outcomes of a decade of robotic versus open catheterizable channel procedures in pediatric patients at their single institution.[46] While a total of 69 patients were included in the study, there were 11 MACE constructions performed each in both the robotic and open groups. Overall, including patients who underwent APV channel construction; there was no difference in continence rates between the robotic and open groups. Furthermore, one of the most recent case series comparing robotic and open MACE outcomes in a cohort of 28 patients was published in 2022 by Saoud et al.[60] Among patients who underwent ACE construction at their institution between 2008 and 2020, there was no difference in estimated blood loss, median LOS, and median time to return to a regular diet. Importantly, the risk of Clavien–Dindo Grade III or higher complications and rate of ACE channel stenosis were significantly higher in the open group. Additionally, rates of channel stenosis were higher in patients with an appendix ACE channel compared to those with cecal flap ACE.
Table 6: Summary of malone antegrade continence enema primary outcomes

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Overall, there is a growing body of evidence supporting the use of robotic-assisted ACE channel creation. Additional evidence of outcomes with longer follow-ups and larger sample sizes are needed, but the usage of robotic assistance for ACE construction appears promising. Concerns about the expenses of robotic surgery in addition to the steep learning curve serve as major limitations. As the field of robotic surgery in pediatrics continues to grow and institutions invest more in robotic equipment, it is expected that robotics will become a more affordable treatment modality due to the disruptive technology phenomenon. These developments warrant increased formalized education in training programs with growing technology to assist. Ultimately, with the continuous advancement of this field, we believe that robotics in pediatric urology will allow for enhanced care and quality of life for children in the near future.

   Conclusions Top

Increasing usage of minimally invasive techniques has shown many benefits in postoperative outcomes such as improved cosmesis, shorter hospitalizations, and decreased postoperative pain. In addition, there is growing evidence that robotic procedures in pediatric urology result in comparable or better outcomes than the traditional open approaches. However, the current literature consists primarily of retrospective studies. Prospective randomized controlled trials are needed to validate and substantiate the reported outcomes.

Financial support and sponsorship: Nil.

Conflicts of interest: There are no conflicts of interest.

   References Top

Sun JY, Granieri MA, Zhao LC. Robotics and urologic reconstructive surgery. Transl Androl Urol 2018;7:545-57.  Back to cited text no. 1
Andolfi C, Kumar R, Boysen WR, Gundeti MS. Current status of robotic surgery in pediatric urology. J Laparoendosc Adv Surg Tech A 2019;29:159-66.  Back to cited text no. 2
Szavay P, Zundel S. Surgery of uretero-pelvic junction obstruction (UPJO). Semin Pediatr Surg 2021;30:151083.  Back to cited text no. 3
Murthy P, Cohn JA, Gundeti MS. Evaluation of robotic-assisted laparoscopic and open pyeloplasty in children: Single-surgeon experience. Ann R Coll Surg Engl 2015;97:109-14.  Back to cited text no. 4
Cundy TP, Harling L, Hughes-Hallett A, Mayer EK, Najmaldin AS, Athanasiou T, et al. Meta-analysis of robot-assisted versus conventional laparoscopic and open pyeloplasty in children. BJU Int 2014;114:582-94.  Back to cited text no. 5
Cohen S, Raisin G, Dothan D, Jaber J, Kocherov S, Chertin B. Robotic-assisted laparoscopic pyeloplasty (RALP), for ureteropelvic junction obstruction (UPJO), is an alternative to open pyeloplasty in the pediatric population. J Robot Surg 2022;16:1117-22.  Back to cited text no. 6
Bansal D, Cost NG, DeFoor WR Jr., Reddy PP, Minevich EA, Vanderbrink BA, et al. Infant robotic pyeloplasty: Comparison with an open cohort. J Pediatr Urol 2014;10:380-5.  Back to cited text no. 7
Neheman A, Kord E, Zisman A, Darawsha AE, Noh PH. Comparison of robotic pyeloplasty and standard laparoscopic pyeloplasty in infants: A Bi-institutional study. J Laparoendosc Adv Surg Tech A 2018;28:467-70.  Back to cited text no. 8
Andolfi C, Rodríguez VM, Galansky L, Gundeti MS. Infant robot-assisted laparoscopic pyeloplasty: Outcomes at a single institution, and tips for safety and success. Eur Urol 2021;80:621-31.  Back to cited text no. 9
Avery DI, Herbst KW, Lendvay TS, Noh PH, Dangle P, Gundeti MS, et al. Robot-assisted laparoscopic pyeloplasty: Multi-institutional experience in infants. J Pediatr Urol 2015;11:5.e1-5.  Back to cited text no. 10
Kawal T, Srinivasan AK, Shrivastava D, Chu DI, Van Batavia J, Weiss D, et al. Pediatric robotic-assisted laparoscopic pyeloplasty: Does age matter? J Pediatr Urol 2018;14:540.e1-540.e6.  Back to cited text no. 11
Kafka IZ, Kocherov S, Jaber J, Chertin B. Pediatric robotic-assisted laparoscopic pyeloplasty (RALP): Does weight matter? Pediatr Surg Int 2019;35:391-6.  Back to cited text no. 12
Tasian GE, Wiebe DJ, Casale P. Learning curve of robotic assisted pyeloplasty for pediatric urology fellows. J Urol 2013;190:1622-6.  Back to cited text no. 13
Spampinato G, Binet A, Fourcade L, Mendoza Sagaon M, Villemagne T, Braik K, et al. Comparison of the learning curve for robot-assisted laparoscopic pyeloplasty between senior and junior surgeons. J Laparoendosc Adv Surg Tech A 2021;31:478-83.  Back to cited text no. 14
Junejo NN, Alotaibi A, Alshahrani SM, Alshammari A, Peters CA, Alhazmi H, et al. The learning curve for robotic-assisted pyeloplasty in children: Our initial experience from a single center. Urol Ann 2020;12:19-24.  Back to cited text no. 15
[PUBMED]  [Full text]  
Dothan D, Raisin G, Jaber J, Kocherov S, Chertin B. Learning curve of robotic-assisted laparoscopic pyeloplasty (RALP) in children: How to reach a level of excellence? J Robot Surg 2021;15:93-7.  Back to cited text no. 16
Andolfi C, Lombardo AM, Aizen J, Recabal X, Walker JP, Barashi NS, et al. Laparoscopic and robotic pyeloplasty as minimally invasive alternatives to the open approach for the treatment of uretero-pelvic junction obstruction in infants: A multi-institutional comparison of outcomes and learning curves. World J Urol 2022;40:1049-56.  Back to cited text no. 17
Varda BK, Wang Y, Chung BI, Lee RS, Kurtz MP, Nelson CP, et al. Has the robot caught up? National trends in utilization, perioperative outcomes, and cost for open, laparoscopic, and robotic pediatric pyeloplasty in the United States from 2003 to 2015. J Pediatr Urol 2018;14:336.e1-336.e8.  Back to cited text no. 18
Bennett WE Jr., Whittam BM, Szymanski KM, Rink RC, Cain MP, Carroll AE. Validated cost comparison of open versus. Robotic pyeloplasty in American children's hospitals. J Robot Surg 2017;11:201-6.  Back to cited text no. 19
Routh JC, Graham DA, Nelson CP. Epidemiological trends in pediatric urolithiasis at United States freestanding pediatric hospitals. J Urol 2010;184:1100-4.  Back to cited text no. 20
Assimos D, Krambeck A, Miller NL, Monga M, Murad MH, Nelson CP, et al. Surgical management of stones: American urological association/endourological society guideline, PART I. J Urol 2016;196:1153-60.  Back to cited text no. 21
Ballesteros N, Snow ZA, Moscardi PR, Ransford GA, Gomez P, Castellan M. Robotic management of urolithiasis in the pediatric population. Front Pediatr 2019;7:351.  Back to cited text no. 22
Roth JD, Gargollo PC, DaJusta DG, Lindgren BW, Noh PH, Rensing AJ, et al. Endoscopic-assisted robotic pyelolithotomy: A viable treatment option for complex pediatric nephrolithiasis. J Pediatr Urol 2020;16:192.e1-192.e5.  Back to cited text no. 23
Esposito C, Masieri L, Blanc T, Lendvay T, Escolino M. Robot-assisted laparoscopic surgery for treatment of urinary tract stones in children: Report of a multicenter international experience. Urolithiasis 2021;49:575-83.  Back to cited text no. 24
Locke RA, Kwenda EP, Archer J, Bergamo J, Domino MP, DeMarco RT, et al. Pediatric robot-assisted laparoscopic and ureteroscopic ureterolithotomy and ureteroplasty. J Endourol Case Rep 2020;6:264-7.  Back to cited text no. 25
Scarcella S, Tiroli M, Torino G, Mariscoli F, Cobellis G, Galosi AB. Combined treatment of ureteropelvic junction obstruction and renal calculi with robot-assisted laparoscopic pyeloplasty and laser lithotripsy in children: Case report and non-systematic review of the literature. Int J Med Robot 2021;17:e2246.  Back to cited text no. 26
Lee RS, Sethi AS, Passerotti CC, Retik AB, Borer JG, Nguyen HT, et al. Robot assisted laparoscopic partial nephrectomy: A viable and safe option in children. J Urol 2009;181:823-8.  Back to cited text no. 27
Neheman A, Kord E, Strine AC, VanderBrink BA, Minevich EA, DeFoor WR, et al. Pediatric partial nephrectomy for upper urinary tract duplication anomalies: A comparison between different surgical approaches and techniques. Urology 2019;125:196-201.  Back to cited text no. 28
Ballouhey Q, Binet A, Clermidi P, Braik K, Villemagne T, Cros J, et al. Partial nephrectomy for small children: Robot-assisted versus open surgery. Int J Urol 2017;24:855-60.  Back to cited text no. 29
Blanc T, Pio L, Clermidi P, Muller C, Orbach D, Minard-Colin V, et al. Robotic-assisted laparoscopic management of renal tumors in children: Preliminary results. Pediatr Blood Cancer 2019;66 Suppl 3:e27867.  Back to cited text no. 30
Bansal D, Cost NG, Bean CM, Riachy E, Defoor WR Jr., Reddy PP, et al. Comparison of pediatric robotic-assisted laparoscopic nephroureterectomy and laparoendoscopic single-site nephroureterectomy. Urology 2014;83:438-42.  Back to cited text no. 31
Sung J, Skoog S. Surgical management of vesicoureteral reflux in children. Pediatr Nephrol 2012;27:551-61.  Back to cited text no. 32
Smith RP, Oliver JL, Peters CA. Pediatric robotic extravesical ureteral reimplantation: Comparison with open surgery. J Urol 2011;185:1876-81.  Back to cited text no. 33
Marchini GS, Hong YK, Minnillo BJ, Diamond DA, Houck CS, Meier PM, et al. Robotic assisted laparoscopic ureteral reimplantation in children: Case matched comparative study with open surgical approach. J Urol 2011;185:1870-5.  Back to cited text no. 34
Gundeti MS, Boysen WR, Shah A. Robot-assisted laparoscopic extravesical ureteral reimplantation: Technique modifications contribute to optimized outcomes. Eur Urol 2016;70:818-23.  Back to cited text no. 35
Sahadev R, Spencer K, Srinivasan AK, Long CJ, Shukla AR. The robot-assisted extravesical anti-reflux surgery: How we overcame the learning curve. Front Pediatr 2019;7:93.  Back to cited text no. 36
Babu R, Chandrasekharam VV. A systematic review and meta-analysis comparing outcomes of laparoscopic extravesical versus trans vesicoscopic ureteric reimplantation. J Pediatr Urol 2020;16:783-9.  Back to cited text no. 37
Boysen WR, Ellison JS, Kim C, Koh CJ, Noh P, Whittam B, et al. Multi-institutional review of outcomes and complications of robot-assisted laparoscopic extravesical ureteral reimplantation for treatment of primary vesicoureteral reflux in children. J Urol 2017;197:1555-61.  Back to cited text no. 38
Boysen WR, Akhavan A, Ko J, Ellison JS, Lendvay TS, Huang J, et al. Prospective multicenter study on robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV): Outcomes and complications. J Pediatr Urol 2018;14:262.e1-262.e6.  Back to cited text no. 39
Esposito C, Castagnetti M, Autorino G, Coppola V, Cerulo M, Esposito G, et al. Robotassisted laparoscopic extra-vesical ureteral reimplantation (Ralur/Revur) for pediatric vesicoureteral reflux: A systematic review of literature. Urology 2021;156:e1-11.  Back to cited text no. 40
Neheman A, Strine AC, Concodora CW, Schulte ME, Noh PH. Outpatient robotic unilateral extravesical ureteral reimplantation in the pediatric population: Short-term assessment of safety. J Urol 2019;201:615-9.  Back to cited text no. 41
Kirsch AJ, Arlen AM. Evolving surgical management of pediatric vesicoureteral reflux: Is open ureteral reimplantation still the 'Gold Standard'? Int Braz J Urol 2020;46:314-21.  Back to cited text no. 42
Kurtz MP, Leow JJ, Varda BK, Logvinenko T, Yu RN, Nelson CP, et al. Robotic versus open pediatric ureteral reimplantation: Costs and complications from a nationwide sample. J Pediatr Urol 2016;12:408.e1-408.e6.  Back to cited text no. 43
Gundeti MS, Petravick ME, Pariser JJ, Pearce SM, Anderson BB, Grimsby GM, et al. A multi-institutional study of perioperative and functional outcomes for pediatric robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy. J Pediatr Urol 2016;12:386.e1-386.e5.  Back to cited text no. 44
Grimsby GM, Jacobs MA, Gargollo PC. Comparison of complications of robot-assisted laparoscopic and open appendicovesicostomy in children. J Urol 2015;194:772-6.  Back to cited text no. 45
Galansky L, Andolfi C, Adamic B, Gundeti MS. Continent cutaneous catheterizable channels in pediatric patients: A decade of experience with open and robotic approaches in a single Center. Eur Urol 2021;79:866-78.  Back to cited text no. 46
Juul N, Persad E, Willacy O, Thorup J, Fossum M, Reinhardt S. Robot-assisted versus. Open appendicovesicostomy in pediatric urology: A systematic review and single-Center case series. Front Pediatr 2022;10:908554.  Back to cited text no. 47
Budzyn J, Trinh H, Raffee S, Atiemo H. Bladder augmentation (Enterocystoplasty): The current state of a historic operation. Curr Urol Rep 2019;20:50.  Back to cited text no. 48
Cheng PJ, Myers JB. Augmentation cystoplasty in the patient with neurogenic bladder. World J Urol 2020;38:3035-46.  Back to cited text no. 49
Gundeti MS, Eng MK, Reynolds WS, Zagaja GP. Pediatric robotic-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy: Complete intracorporeal – Initial case report. Urology 2008;72:1144-7.  Back to cited text no. 50
Murthy P, Cohn JA, Selig RB, Gundeti MS. Robot-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy in children: Updated interim results. Eur Urol 2015;68:1069-75.  Back to cited text no. 51
Cohen AJ, Brodie K, Murthy P, Wilcox DT, Gundeti MS. Comparative outcomes and perioperative complications of robotic versus open cystoplasty and complex reconstructions. Urology 2016;97:172-8.  Back to cited text no. 52
Murthy P, Cohn JA, Gundeti MS. Robotic approaches to augmentation cystoplasty: Ready for prime time? Curr Bladder Dysfunct Rep 2014;9:310-7.  Back to cited text no. 53
Kropp KA. Bladder neck reconstruction in children. Urol Clin North Am 1999;26:661-72, viii.  Back to cited text no. 54
Bagrodia A, Gargollo P. Robot-assisted bladder neck reconstruction, bladder neck sling, and appendicovesicostomy in children: Description of technique and initial results. J Endourol 2011;25:1299-305.  Back to cited text no. 55
Gargollo PC. Robotic-assisted bladder neck repair: Feasibility and outcomes. Urol Clin North Am 2015;42:111-20.  Back to cited text no. 56
Grimsby GM, Jacobs MA, Menon V, Schlomer BJ, Gargollo PC. Perioperative and short-term outcomes of robotic versus open bladder neck procedures for neurogenic incontinence. J Urol 2016;195:1088-92.  Back to cited text no. 57
Gargollo PC, White LA. Robotic-assisted bladder neck procedures for incontinence in pediatric patients. Front Pediatr 2019;7:172.  Back to cited text no. 58
Stifelman MD, Zhao LC, Eun DD, Koh CJ. Techniques of Robotic Urinary Tract Reconstruction: A Complete Approach. Switzerland: Springer International Publishing; 2022.  Back to cited text no. 59
Saoud R, Abou Heidar N, Andolfi C, Gundeti MS. Antegrade colonic enema channels in pediatric patients using appendix or cecal flap: A Comparative robotic versus open series. J Endourol 2022;36:462-7.  Back to cited text no. 60


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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