Nineteen years after the first pediatric robotic pyeloplasty with a da Vinci® Surgical System, robotic surgery in pediatric urology is both well established and continuing to evolve. Initially developed for cardiac and potentially remote surgery, the da Vinci System has found its place solidly within urology and is used for numerous procedures with a high level of success. Controversy remains regarding its true value, and this is certainly the case in pediatric urology. With initial use beginning soon after the introduction of reconstructive laparoscopy, the robotic system offered the potential for much more efficient minimally invasive reconstructive procedures in children. As is often the case, early adapters rapidly explored the possibilities of this new technology. Initial results with pyeloplasty and ureteral reimplantation were generally very good, with success rates comparable to open surgery yet reduced hospital stays. Demonstration of significantly reduced morbidity, however, was difficult, particularly in younger children, where the recovery is often rapid no matter what surgical method is used. While the benefits could be debated, it was clear from initial reports that even small children could be successfully operated on for multiple renal surgeries (see figure), including ureteral, bladder and retrovesical procedures as well. As with any new technology, robotic surgery in pediatric urology had its early and late adaptors.¹

While a small group of surgeons with access to the da Vinci System explored pediatric applications, overall adoption was relatively slow due to several factors.² The system remained very costly both to purchase and maintain. While much easier to learn than conventional laparoscopic techniques, there was still a learning curve that in essence was a cost in itself. In pediatric urological practice, high volume procedures that could justify the cost to an institution are uncommon. Other pediatric specialties were even slower to take up robotic surgery and potentially spread the cost. At the same time, there was skepticism regarding its value, and several reports of alternative approaches including minimally invasive open surgery began to appear. In pediatric practice, there were few meaningful objective parameters to define surgical morbidity, and there has been no generally accepted threshold for morbidity reduction to justify the costs of robotic surgery. Performing rigorous prospective studies in children of highly variable ages can be quite difficult, and only through multicenter studies would adequate numbers be available.

Figure. Horseshoe kidney with upper pole ureteropelvic junction obstruction (left panel) due to stenotic short upper pole ureter is repaired robotically with upper-to-lower pyelopyelostomy and upper and lower pole pyeloplasty (right panel). Pelves have been joined, and ureter is being anastomosed to both.

Nonetheless, the appeal of the robotic system is strong relative to either conventional laparoscopic reconstructive surgery or open surgery. While the difference in outcome may be less evident in a 6-month-old patient, a 15-year-old undergoing robotic pyeloplasty clearly has a faster recovery than one undergoing open pyeloplasty. Having struggled with conventional laparoscopic reconstructive surgery, including pyeloplasty, for several years, the introduction of the robot was a true epiphany. Visualization of the anatomy with a stable 3-dimensional image and wide exposure was exceptional, and the precise and smooth movements capable with the system permitted a sense of control and accuracy far beyond what was possible with conventional laparoscopy, and even open surgery. With mastery of the basic procedures such as pyeloplasty, approaching more complex cases such as reoperative pyeloplasty, partial nephrectomies, ureterocalicostomies and even intrarenal infundibuloplasties became progressively more feasible. It is this natural progressive expansion of capability that must be recognized as an integral part of the evolution of this technology and its potential use in pediatric urology.

At present, application of robotic surgery in pediatric urology is relatively widespread at children’s hospitals and in many pediatric units.³ It is slowly expanding internationally. Without a doubt, pyeloplasty is the most useful technique and is relatively widely used. With experience and dedicated teams, surgical times are very acceptable and can be comparable to open surgery. More complex renal surgery is well described and reported outcomes are very good. Exploration of novel areas such as partial nephrectomy for malignancies in children has begun. Robotic management of vesicoureteral reflux remains less developed, with variable success rates and less enthusiastic uptake. It seems this reflects greater variability in the surgical techniques and in outcome assessment. This is combined with ongoing evolution of the surgical management of reflux as well. One of the most useful applications of the robotic system is in retrovesical procedures, particularly excision of a prostatic utricle or seminal vesicle cysts. This provides a minimally morbid procedure for what used to be quite difficult and uncomfortable for the patient. Complex reconstruction, including augmentation cystoplasty, continues to be explored but the efficiency remains limited and there is a clear need for more efficient operative algorithms.

These challenges and concerns provide direction for the future of pediatric urological robotics. There is a clear need for refinement of surgical algorithms combined with careful assessments and comparisons. Different techniques need to be examined and consensus developed regarding optimal methods to achieve the desired outcome. This speaks to the need for consistent educational efforts with careful attention to quality. Establishment of multicenter groups to study techniques and outcomes has started and will be an important foundation for future development.⁴ Integral to this will be the development of uniform measures of surgical morbidity and outcomes to allow realistic comparisons.

Finally, we can look forward to technological evolution that will further enhance the value of robotic surgery. As Satava has pointed out, the surgical robot is a digital information platform.⁵ In this regard, it can be integrated with other information platforms such as imaging, automation, simulation and artificial intelligence. All of these elements have been explored to some degree. In the future, the clunky da Vinci surgical robot will likely be a ceiling-mounted modular system controlled through a Cloud-based system that permits surgical planning and intraoperative computer-assisted decision-making with postoperative review and learning. The user interface will likely be virtual without clumsy controllers or switches. While this is an exciting and appealing horizon, as clinicians we should continue to keep the focus of the highest quality of patient care at the forefront and rigorously challenge all new technologies with a mindset of skeptical enthusiasm.