During the last 2 decades, robotics in pediatric reconstructive surgery has become progressively more commonplace. Pyeloplasty was first to be performed robotically, followed by ureteral reimplant. In the last decade advanced reconstructive procedures such as bladder augmentation and creation of continent catheterizable channels have been offered robotically.¹ While robotics was only performed at highly specialized pediatric centers initially, it now looks to become the norm at most children’s hospitals. Indeed, according to recent publications, robotic pyeloplasty is rapidly becoming the most common modality for pyeloplasty in the United States.²

Associated with adopting a newer approach such as robotics is a learning curve: the visual representation of an increase in surgical proficiency that occurs with increasing experience. Although the concept is simple enough, defining and studying the learning curve for robotic surgery is quite difficult and heterogenous.³ For example, how does one define competency or expertise? Is it time to complete the procedure, success rate, complication rate, a combination of all 3, or is there a novel method we should be developing? How does one compare the curve of a practicing urologist with considerable open experience to a freshly minted attending with considerable robotic experience? How does one account for variability in surgeon hand–eye coordination or translatable skills? The learning curve must also be different for pioneering surgeons, where optimal performance is not yet known, compared to late adopters. And so we are left with the subjective truth that all surgeons are acutely aware of: that in the early stages, performing a new procedure or using a new technique will have lower success rates, higher complication rates and take longer to perform.

These outcomes and their often-underappreciated emotional cost to the patient, family, and surgeon must be tolerated for an estimated number of cases until the learning curve can be scaled. This aspect cannot be stressed enough, especially in the pediatric population where repeat anesthesia and emotional trauma from surgery may have unknown long-term effects on growing children.

This poses an ethical dilemma for surgeons. Does the potential benefit to the patient (and future patients) outweigh the negatives associated with the pioneering surgeon’s learning curve? Naturally, little literature exists on this subject. How would one even study such a philosophical question? However one feels, innovation is essential to advancement in surgery and is therefore vital to the betterment of patient welfare. In 1994 the American College of Surgeons stated that “it is essential that the value and safety of a new procedure be established before it is widely used on patients.”⁴ This sentiment is echoed by the IDEAL framework laid out by the Balliol Collaboration out of Oxford in 2009.⁵ So in the space between, before value and safety can be reliably established, thorough informed consent of the potential benefits but also of the very real uncertainty of a novel approach should be discussed with the patient and family.⁶

At this point, outcomes for reconstructive procedures have improved to the point where success rates are comparable to the gold standard open procedures (see Appendix). A recent systematic review and meta-analysis showed similar success rates for robotic pyeloplasty, albeit with slightly higher complication rates, when compared to the open approach.⁷ Similarly, a recent meta-analysis has shown that robotic and open ureteral reimplant have similar success and complication rates.⁸ However, early on robotic success rates were highly variable, ranging from 72% to 98%.⁹ This rocky start was likely due to variable techniques that likely prolonged the learning curve compared to pyeloplasty. In our own series, vast improvement in outcomes were seen with strict adherence to a precise surgical protocol that could only be refined and developed after thorough review of previous surgical video and associated outcomes.⁹

While more advanced reconstruction such as augmentation cystoplasty and catheterizable channel are not common enough to have allowed for a systematic review and meta-analysis, we do reports 2 studies comparing open to robotic approaches in this space.^10,11 They show no difference in success or perioperative complication rates. There were significantly longer operative times associated with the robotic approach, although there is no published standard for the open approach. Complication rates remained similar to the open approach when compared to a national database study.¹²

At this point in time, it appears that the success and complication rates for robotic reconstruction are equivalent to those of open surgery, with an increase in operative time and a decrease in length of stay. So is it worth adopting robotics with a learning curve? Those who answer in the negative will focus on the procedure length, the cost of equipment and the emotional burden associated with the learning curve. Those who answer in the affirmative point to the decreased length of stay (and associated human capital gain), the decreased postoperative pain, the pressures of patient preference (and smaller surgical scars) and the possibility of better long-term outcomes as technology and technique improve. Ultimately, we are comparing a new surgical approach (robotics) to the traditional approach, which has been around (and improving) for well over half a century. In the future, we may very well be comparing a novel surgical approach (or alternative to surgery altogether) to robotics. Robotic surgery is following the trend of disruptive technology adoption and is being compared to the conventional gold standard, which is appropriate for evidence-based practice.

That said, there is an emotional toll for pioneering surgeons and patients, even with thorough informed consent and formalized clinical trials when appropriate. To date, this toll has been unavoidable as we strive to advance patient outcomes and the surgical field in general. So what can be done to shorten the learning curve and reduce the footprint of surgical education in this special population, aside from a traditional fellowship?

Quite a lot, actually. Virtual and augmented reality based simulators are widely available. In-person (and online) proctoring is readily available. Minifellowships with hands-on dry and wet lab experience with real-time feedback can drastically shorten a surgeon’s learning curve as well.¹³ Future advances are extremely encouraging, as well. Miniaturization of the instruments is promising and very much needed at this point. Artificial intelligence based evaluation and assistance during robotic surgery may offer a leap in reproducibility not yet seen in the field, as well as a drastic reduction in the learning curve. Additionally, collaborative study groups, such as PURS (Pediatric Urology Robotic Surgery) and others, continue to set the standard, refine surgical steps and strive to further shorten the learning curve. We believe that as the field progresses, as definitions of competency and expertise become standardized and as the learning curve is shortened, the question of whether the learning robotic learning curve is worth it will become easier to answer.