Introduction
The da Vinci Single-Port (SP) robotic surgical platform has expanded options for minimally invasive surgery in pediatric patients. A recent study comparing robotic multiport and SP pyeloplasty in the pediatric population reported no significant difference in operative time, length of hospital stay, pain score, or opioid use.1 For extirpative surgery, the SP robot offers the advantage of a single incision for access, surgery, and specimen removal. Laparoendoscopic single-site nephrectomy in pediatrics has been previously reported with the associated incision in a concealed yet visible site at the umbilicus.2 Here, we present an SP robotic nephroureterectomy using the da Vinci SP system in a pediatric patient where the incision is superior to the pubis and easily hidden by underwear or a bathing suit.
Case Presentation
A 9-year-old female patient (H 1.4 m, W 40 kg) with right collecting system duplication and upper pole ureterocele underwent ureterocele puncture at age 1 month. Postpuncture renal bladder ultrasound showed improved right lower pole hydronephrosis. Repeat voiding cysourethrogram showed vesicoureteral reflux into the right lower pole.
At age 9 years, the patient was referred for surgical management after years of recurrent urinary tract infections (UTIs) refractory to antibiotic prophylaxis. Repeat voiding cysourethrogram showed persistent right lower pole vesicoureteral reflux. An updated nuclear renal scan showed loss of right renal function with a right lower pole differential renal function of 10% and a nonfunctioning upper pole. The left kidney appeared normal.
The patient and family expressed strong preferences for a completely hidden, single-incision surgery. Based on these preferences, decision was made to perform a combined robotic and open nephroureterectomy using the SP robot through a low transverse incision.
In the operating room, the patient was positioned in a modified left lateral decubitus position with a triangular foam wedge under the right flank. The bed was mildly flexed, and the legs were placed in a frog leg position (Figure 1). A single 3-centimeter low transverse incision was made 1.5 fingerbreadths superior to the pubis. A GelPOINT access platform (Applied Medical) was used to create a “floating dock” for the robotic cannula (Figure 2). A 5-mm AirSeal trocar (CONMED) was placed through the GelPOINT to maintain insufflation.
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Figure 1.: Modified left lateral decubitus position surgical positioning illustrating gentle elevation of the right flank (left) and frog-legged positioning of the legs (right).
Figure 2.: GelPOINT access platform allowing a “floating dock” before (top) and after (bottom) docking of the robotic cart.
Hilar vasculature was controlled using the EndoWrist SP clip (Weck Hemo-o-lock) applier. The kidney was released from the retroperitoneum, and the duplex ureters were dissected from the iliac vessels until the most distal point possible. The robot was then undocked, and the remainder of the distal ureterectomy and specimen extraction were completed through the same incision (Figure 3). Console time for the case was 228 minutes. Total operative time was 378 minutes. Estimated blood loss was 100 to 150 cc. There were no perioperative complications. The patient was discharged on postoperative day 2, typical of practice at our institution. At the postoperative visit 1.5 months later, the patient was back to good physical activity with no trouble voiding. The incision healed satisfactorily and was hidden well below the waistline. At 3 months postoperatively, the patient remains off antibiotic prophylaxis and free from UTIs.
Figure 3.: Final 3-centimenter low transverse incision used for total nephroureterectomy, bladder closure, and specimen extraction.
Discussion
Our decision to perform this surgery using a single incision low on the abdomen as opposed to an open, laparoscopic, multiport robotic, or combination approach deserves explanation. One of the family's deterrents to surgery, despite years of recurrent UTIs, was concern for visible incisions. We offered laparoscopic and multiport robotic surgery with concealed incisions but the need to expand one of the incisions for specimen extraction. The family found attractive the concept of single, hidden incision surgery. As this was to be our 10th SP case, we were willing to accommodate the family's preferences after an honest discussion of a combined robotic and open approach based on our evolving experience with the SP robotic platform.
We have identified critical steps for using the platform in pediatric patients. The SP instruments require at least 10-cm working distance from cannula tip to target anatomy. Use of the GelPOINT access allows an extracorporeal floating dock. In the current case, the SP trocar was adjusted “low” in the dock (close to the skin) for surgical steps at the level of the kidney and “high” (further away from the patient) in the dock for surgical steps low in the pelvis. Given there is insufflation leak inherent to this system, an AirSeal system is necessary. The skin incision can be made quite low in the midline (1-1.5 fingerbreadths above the pubis), and the fascial incision can be angled superiorly. This arrangement allows “oblique” angulation of the access sleeve and robotic cannula, allowing instruments to enter the peritoneal cavity without undue pressure on instrument 1 (12 o'clock position) as it traverses the body wall. Use of an extracorporeal, floating dock originating from low in the pediatric pelvis and angled high in the abdomen creates potentially troublesome competition for space between the large SP robotic arm and patients' lower extremities. As is common in multiport robotic surgery, the SP trocar can be lifted (or “burped”) away from the patient to increase instrument clearance; however, this technique is less effective when using a floating dock because weight is lifted with the robotic instruments rather than the cannula. Specifically, with a floating dock from a low transverse incision, we found instrument drive 3 (6 o'clock position) to clash with the patient's knees. To prevent this, we now place patients' legs in a gentle frog-legged position.
Our case has caveats. Suction and irrigation of the lateral retroperitoneum is suboptimal from a position in the low midline. To improve this in the future, we plan to use the SP Access Port which incorporates AirSeal through the side of the sleeve (rather than inserting the AirSeal through the top of the sleeve). This will allow increased maneuverability through the cap of the floating dock. Operative time would be improved with additional staff experience, additional platform experience, and less complex anatomy.
Conclusion
Using the SP robot for nephroureterectomy in a pediatric patient is feasible and facilitates single incision surgery for resection and specimen extraction.
Consent for Publication
The patient's family has given the surgeon permission to submit their child's case to medical journals.
Conflict of Interest
The authors have no financial relationships to disclose nor conflicts of interest with publications on this report.
References
1. Kang SK, Jang WS, Kim SH, et al. Comparison of intraoperative and short-term postoperative outcomes between robot-assisted laparoscopic multi-port pyeloplasty using the da Vinci Si system and single-port pyeloplasty using the da Vinci SP system in children. Invest Clin Urol. 2021;62(5):592.
2. Kim PH, Patil MB, Kim SS, et al. Early comparison of
nephrectomy options in children (open, transperitoneal laparoscopic, laparo-endoscopic single site (LESS), and robotic surgery). BJU Int. 2011;109(6):910-915.
