Over the last several decades, robot-assisted techniques have been increasingly used across surgical specialties, with recent wide acceptance and adaptation to pediatric procedures. As with any new technology, there has been constant improvement in techniques for complex pediatric urological reconstructive cases, such as bladder augmentation. The benefits of the robot-assisted approach for pediatric bladder augmentation justify the adaptation of these techniques in experienced hands.

The first completely intracorporeal robotic pediatric ileocystoplasty with appendicovesicostomy was performed in 2008.¹ The utilization of the robotic technique confers the same benefits in the pediatric population as the adult population, including decreased length of hospital stay, decreased pain and opiate requirement, improved cosmesis, and improved surgical tissue handling.^2,3 At our institution, length of stay has been shown to significantly improve from 8 days to 6 days with the adoption of the robotic technique for bladder augmentation.^1,4 Decreasing postoperative opiate requirement and thereby pulmonary sequelae is meaningful in patients with complex medical problems such as kyphoscoliosis and concomitant restrictive lung diseases. Additionally, it has been shown in porcine models that there are fewer postoperative adhesions utilizing the robotic approach, which is meaningful in children with complex pathologies that may require repeated abdominal surgeries throughout their lifetimes.⁵

In addition to the benefits of the robotic approach in pediatric bladder augmentation, outcomes support its efficacy compared to the open approach with expected improvements in bladder capacity and function.^2,3 While there have been no head-to-head comparisons of complication rates, making outcomes extrapolation flawed, at our institution we have previously reported a 35% 30-day complication rate for the robotic approach compared to 62% with the open approach.³ Data at our institution have shown similar complications rates with regards to bladder rupture, small bowel obstruction, and reaugmentation compared to similarly reported data for the open technique.^3,6-8 Additionally, the robotic approach decreases the risk of wound dehiscence in patients with high body mass indices compared to the open approach.

Despite the demonstrated safety and efficacy of the robotic bladder augmentation in addition to the benefits of robotic surgery, there has been slow adoption of the robotic technique for bladder augmentation. This is due to lack of standardized training in pediatric robotic surgery, smaller working spaces and lower tolerance of pneumoperitoneum in children, relatively low case volumes for complex reconstructive pediatric cases, initial long operative times, a historical preference for open techniques in children, and cost efficacy concerns.

There have been numerous prospective and retrospective series that address these concerns. Just as there was an adoption and teaching learning curve with robotic techniques in the adult population, there has exponential adoption and publication of robotic-assisted laparoscopy in pediatric surgery and pediatric urology, thereby facilitating more widespread training in this surgical technique.⁹ Techniques to address pneumoperitoneum and trocar concerns in children have been evaluated and standardized.³

While the robotic approach does take longer than the open approach, the operative times have acceptably improved with enhancements in procedural efficiencies. Data at our institution demonstrate this with initial reports showing the robotic bladder augmentation (with or without additional procedures such as appendicovesicostomy, bladder neck reconstruction, or antegrade continent enema creation) takes an average of 623 minutes, and later reports showing an average of 573 minutes with the fastest robotic augmentation procedure at 360 minutes.^1,3,4 This compares to an average of 287 minutes for the open procedure at our institution and 318 minutes when looking at National Surgical Quality Improvement Program data.¹⁰ It is worth noting that each patient has a unique anatomy and surgical history including ventriculoperitoneal shunts with associated adhesions that may alter operative time on a case-by-case basis. Thus, with increasing experience, this time gap is closing. A similar trend has been seen in the adoption of other similarly complex robotic procedures, such as the radical cystectomy with intracorporeal urinary diversion.¹¹

The cost of robotic surgery is known to be higher than open equivalents due to the cost of the initial purchase of the robotic system, servicing contracts, and various disposal instruments with limited lifetime uses. While no direct cost analyses have been performed with regards to robotic vs open pediatric bladder augmentation, data extrapolated from adult literature and other pediatric urology literature show that robotics is more costly than laparoscopic or open surgery and should be taken into consideration when evaluating best surgical technique at an institution.

The advent of robotic-assisted bladder augmentation, however, will certainly not replace the need to adequately train pediatric urologists in the open procedure. Pediatric patients requiring complex urologic reconstruction often have had multiple abdominal surgeries, which increases the risk of requiring an open conversion secondary to adhesions, or anatomic considerations such as severe kyphoscopliosis that may preclude the ability to perform a robotic surgery or increase the risk of postoperative neuropraxia due to positioning. Proficiency in the open approach in addition to the robotic approach, therefore, remains pivotal for a well-rounded pediatric urologist.

Robotic surgery is increasingly used for complex pediatric urological cases, such as bladder augmentation. Reports indicate similar safety and efficacy to the open technique. The benefits of utilizing a minimally invasive approach such as decreased pain, decreased hospital length of stay, and improved cosmesis have been shown. The robotic technique may decrease complications secondary to anatomic concerns such as wound dehiscence with high BMI patients or pulmonary complications in patients with restrictive lung disease. Although improvements in operative time and learning curve are evident, the benefits of the robotic approach should continue to be weighed against cost and operative time.