Since its introduction, laparoscopic surgery has gained increasing popularity among pediatric urologists, due to its apparent advantages compared to traditional open surgery. Principally, the minimally invasive approach allows for a significant reduction in the morbidity associated with the open surgical incision, resulting in decreased use of pain medication, quicker recovery and decreased length of hospital stay. However, conventional laparoscopic surgery (CLS) is technically demanding, requiring significant training and experience. Movement of the laparoscopic instruments and manipulation of the tissues may be challenging due to two-dimensional imaging provided by the laparoscope. Moreover, the use of rigid laparoscopic instruments results in the loss of haptic (force and touch) feedback and dexterity (40 compared to 70 of freedom with open surgery). In addition, these instruments allow for the transmission of tremors and require counterintuitive movements (due to the fulcrum effect by the trocars), which adds to the technical challenge and complexity of advanced maneuvers such as intracorporeal suturing. Because of these disadvantages, minimally invasive surgery in pediatric urology has been primarily limited to simple or extirpative surgery such as orchidopexy, varicocelectomy and complete and partial nephrectomy. More complex surgery such as laparoscopic pyeloplasty and laparoscopic ureteral reimplantation could only be performed by a limited number of highly skilled surgeons.
Robotic assisted laparoscopic surgery (RALS) offers a potential solution for performing more complex reconstructive surgery using a minimally invasive approach. RALS provides improved dexterity (increasing the degree of freedom in the instruments), controls tremor and provides scaling of movements for more precise control of the instruments. In addition, it allows for improved visualization by providing a stable visual field, greater depth perception and magnification. The fulcrum effect experienced with CLS is eliminated, restoring proper hand-eye coordination and improving overall ergonomic position. Together, these advantages allow the surgeon to perform laparoscopic movements more precisely and easily, compared to CLS. Despite these technical advantages, adoption of RALS has been limited primarily due to its significant financial cost. The objective of this review is to evaluate the outcomes and cost of RALS in comparison to CLS and open surgery for specific pediatric urological procedures based on the current literature.
Traditionally, the gold standard in the treatment of ureteropelvic junction obstruction (UPJO) is the open dismembered pyeloplasty with high success rates ranging from 90 to 100% . Despite the benefits of being minimally invasive, laparoscopy pyeloplasty failed to be adopted widely due to technical challenges, specifically with the intracorporeal suturing . RALS provided a solution to these challenges, and robotic-assisted laparoscopic pyeloplasty (RALP) is currently the most common robotic procedure performed in pediatric urology . Despite its popularity, there is a paucity of data (seven series) regarding its long-term, clinical outcome [4▪▪]. In addition, there are a limited number of studies that provide a direct comparison between the various surgical approaches for the treatment of UPJO, the majority being retrospective.
The current literature suggests that the long-term success rate is similar between that of open dismembered pyeloplasty, laparoscopy pyeloplasty and RALP. However, laparoscopy pyeloplasty  and RALP [6,7] are associated with lower requirement for and quicker cessation of pain medication and shorter mean length of hospitalization than with open dismembered pyeloplasty. In comparison to open dismembered pyeloplasty, RALP is typically associated with longer operative times due to the need for setting up and docking the robotic system. However, subsequent studies indicated that with the creation of a collaborative protocol between surgeons, nurses and anesthesiologists, the operative times associated with RALP could be significantly reduced, nearing to that of open dismembered pyeloplasty [4▪▪,8]. Moreover, RALP is associated with higher parental satisfaction regarding overall life, impact of the surgery on patient life, burden of postoperative follow-up and size of incision scar when compared to open dismembered pyeloplasty .
In comparison to laparoscopy pyeloplasty, RALP was associated with similar overall operative times with comparable results . As laparoscopy pyeloplasty is not associated with the high equipment cost as with RALP, it may be concluded that laparoscopy pyeloplasty is always preferable over RALP. However, it has been observed that the ureteropelvic anastomosis is easier to perform with RALP, closely emulating the movement and techniques used during open surgery . As additional laparoscopic skills are not needed, the learning curve for RALP may be markedly abbreviated requiring little previous robotic or laparoscopic experience [11▪]. Sorensen et al. found that the learning curve for RALP appears to be 15–20 cases with excellent safety and efficacy outcomes.
Although it is the gold standard in the management of vesicoureteral reflux (VUR), open ureteral reimplantation (OUR) is associated with significant morbidity such as postoperative pain, hematuria, irritative bladder symptoms, ureteral obstruction and persistent or de-novo VUR . Less invasive approaches have been developed to minimize the morbidity associated with ureteral reimplantation. Conventional laparoscopic ureteral reimplant (CLUR) is a technically demanding procedure and requires a steep learning curve for even the more experienced surgeons . This technique has failed to achieve success rates comparable to open reimplantation likely due to the difficult dissection and suturing of the bladder required . With robotic assistance, the laparoscopic approach has become more feasible resulting from the improved visualization and the increased maneuverability of the instruments [1,15].
Like OUR, robotic assisted laparoscopic ureteral reimplant (RALUR) can be performed either through an intravesical or extravesical approach. Intravesical RALUR is indicated in the treatment of bilateral VUR or when management of concurrent bladder anomalies such as ureterocele or bladder diverticulum is required. Currently, there are only two small series reporting the outcomes of intravesical RALUR. In 2005, Peters and Woo  reported on six patients undergoing bilateral intravesical RALUR with a 91.7% success rate. They had one complication in which urine leakage developed postoperatively from one of the trocar sites. In 2011, Marchini et al.[17▪] reported on 19 patients who underwent intravesical RALUR; they performed a case match comparison with 22 patients undergoing intravesical OUR. The authors observed that RALUR was associated with less bladder spasm, less hematuria, shorter hospital stay and shorter duration of Foley catheter drainage. However, RALUR required longer operative times compared to OUR. In the RALUR group, one patient had transient urinary retention and four patients had a bladder leak from the trocar site; all patients resolved with clinical support and did not require any surgical intervention. The bladder leak complication was subsequently eliminated by modification of the trocar site closure technique. Compared to the extravesical approach, intravesical RALUR is technically more challenging, associated with difficulties in maintaining pneumovesicum (either through leakage around the trocars or retroperitoneally following ureter dissection) and the inability to perform the procedure in young children due to the small bladder size (<130 ml) . However, this challenge may be overcome with the introduction of the Surgiquest apparatus, which maintains pneumoperitoneum by increasing flow when sensing CO2 leaks.
Compared to the intravesical approach, extravesical RALUR is more commonly performed. It is indicated in the treatment of both unilateral and bilateral VUR. Bilateral open extravesical ureteral reimplantation can be associated with transient urinary retention (up to 10%) and consequently, is not routinely performed. The robotic approach with its three-dimensional visualization appeared to minimize the risk of voiding dysfunction by allowing more careful dissection and avoiding nerve injury . Several studies have demonstrated that the success rate of extravesical RALUR is similar to that of OUR; however, it is not without the potential for complications. Peters  reported on 19 patients who underwent extravesical RALUR; two had a bladder leak postoperatively and one had ureteral obstruction. In 2008, Casale et al. reported a 98.8% success rate with only one patient having persistent VUR, and no patients developed urinary retention. In 2011, Marchini et al.[17▪] reported on 20 patients who underwent extravesical RALUR and performed a case–control comparison with 17 patients who underwent extravesical OUR. The authors observed that the robotic group had a similar incidence of significant pain, bladder spasms, duration of Foley catheter drainage and hospital stay compared to the OUR group. In addition, two patients in the robotic group had transient (<24 h) urinary retention, and two had a ureteral leak requiring treatment with a Double-J stent. The results indicated that although it is technically feasible to perform extravesical RALUR, there is not a significant reduction in morbidity compared to extravesical OUR. However, it should be noted that many patients who underwent extravesical RALUR had bilateral VUR and would have otherwise required intravesical OUR. Extravesical RALUR is associated with less incidence of postoperative pain, hematuria and irritative bladder symptoms compared to intravesical OUR. Moreover, RALUR is still in its infancy and as with any surgical procedure, the complication rate and severity will likely decrease with greater experience.
COMPLETE AND PARTIAL NEPHRECTOMY
Laparoscopic complete/partial nephrectomy recently has replaced the open approach as the treatment of choice in the removal of nonfunctioning renal units or segments. The laparoscopic approach is well tolerated and offers significant advantages over open surgery including decreased postoperative pain, shorter hospitalization and improved cosmesis. As this procedure does not require complex laparoscopic skills such as intracorporeal suturing, the application of robotics may seem costly and unnecessary. However, the RAL approach may be advantageous when performing partial nephrectomy, a more technically demanding procedure. In addition, it may be ideal for teaching robotic surgery as nephrectomy is a relatively simple ablative procedure that does not require significant reconstructive capabilities and, thus, can provide training for more complex procedures .
There are only a limited number of studies in the literature regarding RAL nephrectomy. Lee et al. in 2010 reported a small series of three patients who underwent RAL nephrectomy and contralateral ureteral reimplantation. Although there was no complication associated with the nephrectomy, one of the patients developed ureteral obstruction from the antireflux surgery, requiring stenting for 3 weeks. Anderberg et al. reported on a series of 72 RAL nephrectomies. Thirty-nine were performed via an open approach, 11 with conventional laparoscopy (CL), 11 with single site laparoscopy and 11 with robotic assistance . The authors observed that the minimally invasive modalities were associated with shorter lengths of hospital stay and decreased postoperative pain medication usage but longer operative times when compared to open surgery. Similar operative times, postoperative use of pain medication and length of hospital stay were noted among the three minimally invasive modalities.
Similarly, RAL partial nephrectomy has been demonstrated to be feasible and well tolerated. It can be performed through a transperitoneal or retroperitoneal approach. Oslen and Jorgensen  reported on 14 patients who underwent retroperitoneal RAL heminephrectomy. In two cases, open conversion was required, one for bleeding and one for limited working space. Given the limited space of retroperitoneum that could potentially restrict the placement and movement of the robotic system, many pediatric urologists prefer to perform the procedure transperitoneally. Lee et al. reported on nine patients who underwent transperitoneal RAL heminephrectomy. There were no intraoperative complications. Postoperatively, one child developed an asymptomatic urinoma, which was treated with percutaneous drainage. Anecdotally, those surgeons who utilized the robotic system for this procedure believe that it is easier to perform than CL, especially during the mobilization of the upper pole ureter away from the lower pole vasculature. Currently, there have been no studies that compared the CL to the RAL approach. Consequently, it remains to be seen whether RAL has significant advantages over the CL approach for performing partial nephrectomy.
ENTEROCYSTOPLASTY AND CREATION OF CONTINENT CATHETERIZABLE CHANNELS
The use of laparoscopic surgery for lower urinary tract reconstruction has slowly progressed over the past two decades. This is principally due to the high technical complexity of the procedures with the associated steep learning curve and high potential for complications. RALS has allowed for more rapid advancement of performing these procedures less invasively. Nevertheless, this experience is still limited, and only small series and case reports have been reported in the literature. Wille et al. in 2010 reported on their early experience with RAL appendicovesicostomy (Mitrofanoff) in three patients with prune-belly syndrome. The authors did not have any intraoperative complications or require conversions to open surgery. They did, however, have one patient who developed a postoperative wound infection. Nguyen et al. subsequently reported on a series of 10 patients with neuro or myogenic bladder who underwent RAL appendicovesicostomy. One surgery required open conversion due to an inadequate appendix discovered during the procedure. Another developed urinary leakage postoperatively and required an open revision. Minor incontinence developed in two patients, one was corrected with dextranomer/hyaluronic acid injection and one resolved without intervention. The authors concluded that the procedure was feasible to perform and had satisfactory outcomes and minimal complications.
Passerotti et al. were the first to report the use of RALS for performing enterocystoplasty in an ovine model, defining the techniques and pitfalls. In 2010, Gundeti et al. reported on six patients with neurogenic bladder due to spina bifida who underwent RAL enterocystoplasty. One patient required conversion to open surgery due to failure to progress. Three patients had postoperative complications (a wound infection, a lower extremity venous thrombus and a temporary unilateral lower extremity paresthesia). Postoperatively, three patients required revision of their stoma at the skin level for stomal stenosis. The authors observed that all patients were continent and none experienced urinary tract infections. Currently, experience with RAL enterocystoplasty is extremely limited. Long-term follow-up studies are required to evaluate whether its success rate is comparable to that of open surgery and whether there are significant advantages (in terms of recovery time, postoperative pain and improved aesthetic appearance) over open surgery.
The cost of RALS is the principal limitation in the widespread adoption of this surgical approach. For pediatrics, there are very few studies evaluating the cost of RALS. Anderberg et al. compared the cost of robotic fundoplication to that of open surgery and CLS. The authors observed that RAL fundoplication was 9% less expensive than open surgery, but 7% more expensive than CLS. Despite the cost of the longer operative times, the shorter hospitalization associated with RALS accounted for the lower cost when compared to open surgery. The difference between RALS and CLS was primarily due to the cost of robotic instruments that have a limited number of uses. Behan et al. reported that children who underwent RALS had shorter hospital stay. This correlated with significant savings in lost parental wages and hospitalization expenses. However, the cost savings were not achieved by varying the length of stay when amortized costs of the robotic system were included. Finally, Rowe et al.[31▪▪] performed a retrospective, observational, matched cohort study of 146 children undergoing either urologic open surgery or RALS. Patients were matched based on surgery type, age and fiscal year. Direct internal costs from the institution were used to compare the two surgery types across several procedures including pyeloplasty and ureteral reimplant. The cost of RALS was 12% less than that of open surgery. This cost difference was primarily because of the difference in hospital length of stay between open surgery and RALS. Maintenance fees and equipment expenses were the primary contributors to RALS costs, whereas open surgery costs were affected most by room and board expenses. When estimates of the indirect costs of robot purchase and maintenance were included, open surgery had a lower total cost. In this study, cost comparison was made between open surgery and RALS. The CLS alternative for these procedures was not possible, and hence, could not be evaluated. Consequently, the authors’ conclusions are limited to procedures in which RALS is the only minimally invasive alternative available. Together, these studies suggest that less expensive robotic systems and instruments and shorter operating time will allow RALS to be cost-efficient in the future.
Direct comparison between open surgery, CLS and RALS is lacking and consequently, the superiority of one modality over another has yet to be determined. In this case, superiority is not only based on clinical outcomes such as success and complication rates but also on durability of the success and cost. Although the experience with RALS in pediatric urology is still limited, RALS has been shown to be feasible and well tolerated in performing specific pediatric urological procedures. It provides the added benefits of enabling the performance of complex reconstructive procedures such as pyeloplasty, ureteral reimplantation and enterocystoplasty, which are too technically demanding for CLS. In the future, with experience, RALS will likely achieve comparable success and complications relative to open surgery. More importantly, the entry of additional robotic system manufacturers will allow for lower capital and instrument costs, making RALS economically more feasible.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
- ▪▪ of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 101).
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