*3.1.3 Pyeloplasty*

Robot-assisted pyeloplasty is the most common procedure performed robotically in pediatric patients, both within urology and overall [76]. The excellent experience with robot-assisted pyeloplasty has challenged other approaches as a new standard for the treatment of UPJ obstruction.

Dismembered pyeloplasty (Anderson-Hynes) includes resection of the UPJ and reduction of the renal pelvis. In the technique, the ureter is incised and spatulated laterally to provide sufficient ureteral wall length to achieve a wide side-to-side anastomosis. Once the anterior layer of the pelvic-ureteral anastomosis has been sutured, an antegrade transanastomotic double-J stent is passed. J-Vac transabdominal drainage was used in the surgical bed.

Patients undergoing robotic pyeloplasty have a shorter hospital stay, and less need for analgesics; however, there is no difference in the success rate of robotic pyeloplasty in comparison to the other two approaches [77–79].

In robotic pyeloplasty the learning curve is much shorter. This allows some surgeons to transition from the open pyeloplasty to the robotic approach without any prior laparoscopic experience with this technique [80].

Pyeloplasty in infants less than 10 kg has been performed successfully. A multiinstitutional study of 60 infants less than 12 months old with a 91% success rate and an 11% complication rate, which is similar to other studies on larger children and adults [81]. The foregoing supports the personal experience of the author.

Also, the retroperitoneal robotic approach is indicated mainly for patients with previous abdominal surgery, when adhesion syndrome is suspected, and it has been validated for pyeloplasty and other techniques in this anatomical area [82].

#### *3.1.4 Ureteroureterostomy*

The procedures performed included pyeloureterostomy for incomplete duplication and lower pole UPJ obstruction and ipsilateral ureteroureterostomy along with distal ureterectomy for obstruction in a dysplastic upper pole with ureteral, ectopia, for the treatment of duplex anomalies and reconstruction of obstructed dilated ureteral segments [83]. This can also be applied to the lower ureter in duplex systems where it helps to avoid reimplantation of disparate ureters in the same tunnel. Also, transperitoneal robotic ureteroureterostomies have been reported for mid ureteric strictures and also for the correction of retrocaval ureters [84, 85]. Also with robotic assistance, the removal of a large ureteric stone at any level with the placement and closure of a stent is a relatively simple affair, using the Mikulicz procedure to close the ureterotomy or a spatulate anastomosis.

### *3.1.5 Ureterocalicostomy*

Ureterocalicostomy is a potential, and technically feasible option in patients with UPJ obstruction and significant lower pole caliectasis which is often reserved for patients with a failed pyeloplasty and a minimal pelvis, or patients with an exaggerated intrarenal pelvis [86]. An ureterocalicostomy is a procedure in which the ureter is sutured to the lowermost calyx of the kidney. It is a salvage operation, which should be in the arsenal of every surgeon operating the UPJ [87]. The robotic approach is a good option.

#### **3.2 RAS on the lower urinary tract**

## *3.2.1 Extravesical ureteral reimplantation*

The most performed procedure in the lower urinary tract in children is the antireflux ureteral reimplantation [13]. Indications for the surgical treatment of pediatric vesicoureteral reflux include severe urinary tract infections while taking continuous antibiotics prophylaxis, renal scarring, and worsening or non-resolution vesicoureteral reflux. Robotic ureteral reimplantation can be done by an extravesical or intravesical approach and, of these approaches, the extravesical is much more widely reported [88, 89]. The extravesical procedure is a ureteral reimplantation according to the well-established technique of Lich-Gregoir, for achieving an antireflux mechanism. This technique is an accepted alternative to endoscopic treatment and open reimplantation techniques in pediatric patients [73]. However, open surgery remains the gold standard for ureteral reimplantation [90].

**33**

*Robotic-Assisted Minimally Invasive Surgery in Children DOI: http://dx.doi.org/10.5772/intechopen.96684*

vesicoureteral reflux in children [92].

*3.2.3 Augmentation cystoplasty*

*3.2.2.1 Appendicovesicostomy (Mitrofanoff)*

*3.2.2 Appendico-vesicostomy and continent catheterizable channels*

The long-term results of the antireflux procedure are evaluated in terms of preservation of differential renal function, absence of urinary tract infections, and adequate urinary drainage, with a follow-up of more than one year [91]. In a prospective study of children undergoing robot extravesical ureteral reimplantation at eight academic centers from 2015 to 2017, 143 patients (199 ureters). The majority of ureters (73.4%) had grade III or higher vesicoureteral reflux preoperatively. Radiographic resolution was present in 93.8% of ureters. Robotic ureteral reimplantation should be considered as one of several viable options for management of

Complete bladder emptying in children with bladder emptying dysfunction (neuropathic bladder) is achieved with clean intermittent catheterization (CIC). In 1980, Mitrofanoff described his technique of a continent appendicovesicostomy for patients when transurethral CIC cannot be carried out for any reason. When medical therapy fails in the neuropathic bladder, the surgery aims to preserve upper tract function and social continence. A cystostomy with a continent opening easy to catheterize and associated with a closure of the vesical neck, was the objective. The tip of the appendix opened into the bladder at the end of an antireflux submucosal tunnel and the other end hemmed to the skin. The bladder neck is usually closed in the same operation. The continence of the vesicostomy is total and the comfort obtained is excellent [93]. The surgical technique is analogous to the Lich-Gregoir technique, to create an antireflux mechanism. The appendicocutaneostomy can be placed in the umbilicus or in the right lower abdominal quadrant [73]. Robotic continence procedures have been shown to be a safe and effective alternative [94]. An important point is to assess whether a simultaneous bladder augmentation is performed [95].

In patients with neurogenic bowel and bladder secondary to spinal dysraphism who tend to have multiple limb spasms and spinal scoliosis, RAS is a good option [96]. Complex lower urinary tract reconstruction defined as reconstruction of the bladder neck or catheterizable continent ducts, or both, as well as the creation of an antegrade Malone continence enema, for better management of constipation [97].

Augmentation cystoplasty often performed in the context of other reconstructive procedures such as appendicovesicostomy or bladder neck reconstruction. The procedure of bladder augmentation can be performed using a mega-ureter when nephrectomy is anticipated. At present day, the ileocystoplasty represents the currently accepted standard of care [73]. In robotic technique, a 20 cm segment of ileum is selected and isolated. Intestinal continuity is restored, and in the postoperative, the bladder is drained with a suprapubic tube, a urethral catheter and another catheter through the Mitrofanoff channel [98]. Another tissue option for bladder augmentation is the sigmoid colon, this technique significantly improved urodynamic parameters, such as bladder accommodation and filling pressure in

The miscellaneous pediatric urology procedures are some surgeries in the pelvic area, a narrow field that is ideal for the robotic approach. There are reports from

children with myelomeningocele-associated neurogenic bladder [99].

**3.3 Pediatric urology miscellaneous procedures**

*Robotic-Assisted Minimally Invasive Surgery in Children DOI: http://dx.doi.org/10.5772/intechopen.96684*

*Latest Developments in Medical Robotics Systems*

*3.1.4 Ureteroureterostomy*

*3.1.5 Ureterocalicostomy*

approach is a good option.

**3.2 RAS on the lower urinary tract**

*3.2.1 Extravesical ureteral reimplantation*

the ureterotomy or a spatulate anastomosis.

Patients undergoing robotic pyeloplasty have a shorter hospital stay, and less need for analgesics; however, there is no difference in the success rate of robotic

In robotic pyeloplasty the learning curve is much shorter. This allows some surgeons to transition from the open pyeloplasty to the robotic approach without

adults [81]. The foregoing supports the personal experience of the author.

validated for pyeloplasty and other techniques in this anatomical area [82].

Pyeloplasty in infants less than 10 kg has been performed successfully. A multiinstitutional study of 60 infants less than 12 months old with a 91% success rate and an 11% complication rate, which is similar to other studies on larger children and

Also, the retroperitoneal robotic approach is indicated mainly for patients with previous abdominal surgery, when adhesion syndrome is suspected, and it has been

The procedures performed included pyeloureterostomy for incomplete duplication and lower pole UPJ obstruction and ipsilateral ureteroureterostomy along with distal ureterectomy for obstruction in a dysplastic upper pole with ureteral, ectopia, for the treatment of duplex anomalies and reconstruction of obstructed dilated ureteral segments [83]. This can also be applied to the lower ureter in duplex systems where it helps to avoid reimplantation of disparate ureters in the same tunnel. Also, transperitoneal robotic ureteroureterostomies have been reported for mid ureteric strictures and also for the correction of retrocaval ureters [84, 85]. Also with robotic assistance, the removal of a large ureteric stone at any level with the placement and closure of a stent is a relatively simple affair, using the Mikulicz procedure to close

Ureterocalicostomy is a potential, and technically feasible option in patients with UPJ obstruction and significant lower pole caliectasis which is often reserved for patients with a failed pyeloplasty and a minimal pelvis, or patients with an exaggerated intrarenal pelvis [86]. An ureterocalicostomy is a procedure in which the ureter is sutured to the lowermost calyx of the kidney. It is a salvage operation, which should be in the arsenal of every surgeon operating the UPJ [87]. The robotic

The most performed procedure in the lower urinary tract in children is the antireflux ureteral reimplantation [13]. Indications for the surgical treatment of pediatric vesicoureteral reflux include severe urinary tract infections while taking continuous antibiotics prophylaxis, renal scarring, and worsening or non-resolution vesicoureteral reflux. Robotic ureteral reimplantation can be done by an extravesical or intravesical approach and, of these approaches, the extravesical is much more widely reported [88, 89]. The extravesical procedure is a ureteral reimplantation according to the well-established technique of Lich-Gregoir, for achieving an antireflux mechanism. This technique is an accepted alternative to endoscopic treatment and open reimplantation techniques in pediatric patients [73]. However, open

surgery remains the gold standard for ureteral reimplantation [90].

pyeloplasty in comparison to the other two approaches [77–79].

any prior laparoscopic experience with this technique [80].

**32**

The long-term results of the antireflux procedure are evaluated in terms of preservation of differential renal function, absence of urinary tract infections, and adequate urinary drainage, with a follow-up of more than one year [91]. In a prospective study of children undergoing robot extravesical ureteral reimplantation at eight academic centers from 2015 to 2017, 143 patients (199 ureters). The majority of ureters (73.4%) had grade III or higher vesicoureteral reflux preoperatively. Radiographic resolution was present in 93.8% of ureters. Robotic ureteral reimplantation should be considered as one of several viable options for management of vesicoureteral reflux in children [92].

## *3.2.2 Appendico-vesicostomy and continent catheterizable channels*

### *3.2.2.1 Appendicovesicostomy (Mitrofanoff)*

Complete bladder emptying in children with bladder emptying dysfunction (neuropathic bladder) is achieved with clean intermittent catheterization (CIC). In 1980, Mitrofanoff described his technique of a continent appendicovesicostomy for patients when transurethral CIC cannot be carried out for any reason. When medical therapy fails in the neuropathic bladder, the surgery aims to preserve upper tract function and social continence. A cystostomy with a continent opening easy to catheterize and associated with a closure of the vesical neck, was the objective. The tip of the appendix opened into the bladder at the end of an antireflux submucosal tunnel and the other end hemmed to the skin. The bladder neck is usually closed in the same operation. The continence of the vesicostomy is total and the comfort obtained is excellent [93].

The surgical technique is analogous to the Lich-Gregoir technique, to create an antireflux mechanism. The appendicocutaneostomy can be placed in the umbilicus or in the right lower abdominal quadrant [73]. Robotic continence procedures have been shown to be a safe and effective alternative [94]. An important point is to assess whether a simultaneous bladder augmentation is performed [95].

In patients with neurogenic bowel and bladder secondary to spinal dysraphism who tend to have multiple limb spasms and spinal scoliosis, RAS is a good option [96]. Complex lower urinary tract reconstruction defined as reconstruction of the bladder neck or catheterizable continent ducts, or both, as well as the creation of an antegrade Malone continence enema, for better management of constipation [97].

#### *3.2.3 Augmentation cystoplasty*

Augmentation cystoplasty often performed in the context of other reconstructive procedures such as appendicovesicostomy or bladder neck reconstruction. The procedure of bladder augmentation can be performed using a mega-ureter when nephrectomy is anticipated. At present day, the ileocystoplasty represents the currently accepted standard of care [73]. In robotic technique, a 20 cm segment of ileum is selected and isolated. Intestinal continuity is restored, and in the postoperative, the bladder is drained with a suprapubic tube, a urethral catheter and another catheter through the Mitrofanoff channel [98]. Another tissue option for bladder augmentation is the sigmoid colon, this technique significantly improved urodynamic parameters, such as bladder accommodation and filling pressure in children with myelomeningocele-associated neurogenic bladder [99].

#### **3.3 Pediatric urology miscellaneous procedures**

The miscellaneous pediatric urology procedures are some surgeries in the pelvic area, a narrow field that is ideal for the robotic approach. There are reports from

RAS of; symptomatic bladder diverticulum excision [36], symptomatic or malignant urachal cyst excision [100], posterior urethral diverticula excision, mainly after surgical reconstruction of imperforate anus [101], prostatic utricle removal, is a malformation due to incomplete regression of Müllerian ducts [102], and varicocele cure, a condition that has a significant association with infertility [103].
