The utilization of robotic platforms in pediatric urology has experienced rapid growth in recent years. It offers many of the same advantages of straight laparoscopy including decreased pain and blood loss along with fast recovery and improved cosmesis. However, robotic surgery offers ergonomic advantages. Upper tract reconstructive procedures such as pyeloplasty are a key example of the robotic platform popularity where, at least in the US, it may have overtaken other techniques as the preferred choice.¹ This should come as no surprise, given the expedited learning curve to master complex reconstructive laparoscopic techniques with the robot as compared to conventional laparoscopy. This is especially true for cases requiring a significant amount of intracorporeal suturing, such as bladder augmentations. The combination of the abovementioned advantages with the improved ability to work in small places such as the pelvis makes this platform ideal for lower tract reconstruction. In the modern era, the surgical robot has opened the door for a minimally invasive approach to complex lower reconstructive cases such as bladder neck reconstruction, Mitrofanoff procedure, and bladder augmentation.

The expectation then becomes that children with neurogenic bladder requiring these types of procedures could benefit from the well-established advantages of minimally invasive surgery. The complex nature of these reconstructive cases, which often must be performed together, has been difficult to master using a straight laparoscopic technique. Robotic platforms have made these procedures feasible and safe, but it remains unclear if minimally invasive options indeed offer advantages when compared to open surgery.

As pediatric urologists continue to gain experience using the robotic platform, expanding the operative repertoire to complex reconstructive lower tract procedures is the logical next step. Yet this can be seen as daunting, and surgeons are often discouraged from attempting new procedures despite having the necessary skills. Most robotic lower tract reconstruction follows the same techniques as the open counterpart. However, the overall technique is not new. The only novelty is using the surgical robot to accomplish the laparoscopic technique. It is expected that a well-trained pediatric urologist would be able to perform open complex lower tract reconstruction, and robotic surgery has become a ubiquitous component of residency and fellowship training. Thus, combining these 2 skills should be all that is required to attempt robotic lower tract reconstruction in a pediatric patient with a neurogenic bladder.

Minimally invasive techniques to create a Mitrofanoff channel have been described with both straight laparoscopic techniques and the robot. The Mitrofanoff creation is the ideal fundamental case for a young surgeon looking to begin performing lower tract reconstruction (part D of Figure). Gundeti et al, in a multicenter study with 88 patients undergoing robotic Mitrofanoff, showed that the technique is reproducible across centers.² Additionally, this study demonstrated that the robotic technique had comparable complication rates and functional outcomes to previously published series using an open technique.

Figure. A, Bladder neck reconstruction anterior dissection. B, Bladder neck reconstruction prior to sling wrap. C, Bladder augmentation, starting to attach the bowel patch to the bladder. D, Mitrofanoff implanted in the bladder.

As the surgeon’s experience increases, bladder neck reconstruction is the next logical step in advancing expertise in lower urinary tract reconstruction (parts A and B of Figure) This procedure, by its nature, makes catheterization via the urethra difficult and often requires the concomitant creation of a Mitrofanoff. Thus, it is important for the surgeon to be already comfortable with the Mitrofanoff creation. Grimsby et al showed that this procedure is feasible robotically and offers similar continence results compared to the open technique with similar complication rates.³ As expected with the robotic technique, operative times were longer. In this study, however, hospital stay was not significantly improved as compared to the open approach.

Finally, bladder augmentation is the most challenging, and thus advanced, procedure to attempt robotically (part C of Figure). This surgery is often long, even when done open, which makes finding a patient who requires an augmentation alone ideal for the first attempt of a robotic case. It comes as no surprise, however, that while robotic bladder augmentation is feasible and safe, it is associated with prolonged operative time as compared to the open technique.⁴ Unfortunately, these patients often require concomitant bladder neck procedures, Mitrofanoff channel, and/or possible antegrade enema options, further prolonging operative duration. Ultimately, the surgeon will have to consider if the benefits of accomplishing the procedure using laparoscopic technique outweigh the significant increase in operative time associated with robotic-assisted bladder augmentation. Indeed, operative duration is a concern for most robotic-assisted lower tract reconstruction cases.

Ultimately, patients with neurogenic bladder, in particular myelomeningocele patients, are complex, often with multiple comorbidities, including neurogenic bowel, which increases the risks associated with any type of major surgical intervention. Patients often have prior abdominal procedures that do not preclude a minimally invasive approach but do make it more challenging, especially when a ventriculoperitoneal shunt is present.⁵ Additionally, the number of patients requiring intervention is small and conservative management has further decreased the number of procedures done each year. These 2 factors limit the ability to perform the number of cases necessary to achieve mastery, as well as adequately study whether or not there is a significant benefit of the robotic approach over the open approach in lower tract reconstruction for these patients. Nonetheless, introducing robotic reconstructive techniques is feasible and should be done in a stepwise approach to build surgeons’ skills, improve outcomes, and minimize complications.