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C. Tao and L. Sun
sion to open abdominal surgery due to massive
bleeding.
Indications:
(a) Split renal function <10%;
(b) Recurrent urinary tract infections;
(c) Drip urine or continuous wet pants, consider-
ing ectopic ureteral orice.
Contraindications:
With the progress of technology, accumulation of experience, and upgrading of equipment,
some contraindications of robotic surgery will
gradually become relative contraindications or
indications, but there are still some cases that are
not suitable for robotic surgery.
(a) Vital signs are unstable, the function of
important organs is poor, such as cardiopulmonary function, and pneumoperitoneum
that cannot be tolerated;
(b) Urinary tract infection has not been
controlled;
(c) History of severe abdominal trauma or severe
adhesion in the surgical area;
(d) Solitary kidney or bilateral polycystic renal
dysplasia;
(e) Secondary renal dysplasia caused by the
congenital posterior urethral valve.
23.3 Preoperative Preparation
Due to the limited abdominal space, robotic surgery for children, especially infants, is a difcult
and high-risk operation. Adequate preoperative
preparation is particularly important for the smooth
implementation of the whole operation process and
postoperative recovery. The kidney is an important
organ of the human body. It has the functions of
removing internal metabolites and regulating
water, electrolyte, and acid-base balance, as well as
endocrine function, which is very important to
ensure the stability of the internal environment.
Therefore, strict indications are needed when planning the surgical procedures of nephrectomy.
(a) Preoperative laboratory examination: routine
blood tests, urine tests, fecal tests, liver and
kidney function tests, electrolyte, blood glucose, blood type, etc.;
(b) Perfect preoperative imaging examination:
ultrasonic Doppler and MRU examination
should be performed to understand the size
and location of the affected kidney and the
possibility of ectopic kidney. Preoperative
VCUG examination should be performed to
understand whether there is vesicoureteral
reux and a posterior urethral valve.
Preoperative ECT examination should be
performed to understand renal function and
provide a basis for nephrectomy. Personalized
surgical plans need to be formulated, and
possible risks are fully assessed;
(c) Preoperative nutritional support could correct
malnutrition. If necessary, preoperative blood
transfusion could correct severe anemia;
(d) Preoperative drug adjustment: urinary tract
infection should be controlled before surgery, and prophylactic broad-spectrum antibiotics 24h before surgery are recommended
to reduce the risk of postoperative infection;
(e) Vaccination: children undergoing elective
nephrectomy can receive preventive multiple
vaccines, including pneumonia vaccine,
inuenza vaccine, and meningitis vaccine,
twoweeks before operation; children undergoing emergency surgery can also be vaccinated 30days after surgery;
(f) Routine preoperative preparation: gastroin-
testinal preparation, preoperative fasting for
8 h, preoperative water prohibition for 2h,
emptying the intestine by glycerine enema,
skin preparation, catheterization, preoperative disinfection, and correction of hydroelectrolyte disorder if necessary;
(g) Surgical instruments: select the appropriate
surgical instruments according to the condition of the child, and regularly equip with an
ultrasonic scalpel or ligator. Due to the risk
of massive intraoperative bleeding, it is recommended that qualied units use autologous blood transfusion devices.
E
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23.4 Position andDocking
Surgical position should be determined according to the patient’s condition.
(a) The affected side kidney is in situ: the patient
takes the healthy side lying position, the
affected side is padded 50–70°, the abdominal wall is close to the edge of the bed, the
affected side upper limb droops naturally,
and the healthy side upper limb is abducted
and supported by a hand support plate. The
lower limb of the healthy side was exed
downward, and the lower limb of the affected
side was exed slightly backward and downward. All stressed parts are padded with
sponge pads and xed with adhesive tape. An
8mm lens was inserted around the umbilicus
to establish pneumoperitoneum and maintain
the pneumoperitoneum pressure of
8–10 mmHg. Two 8 mm dermatoglyphic
incisions were respectively made on the
Pfannestiel line in the middle of the umbilicus and under the xiphoid process in the
middle of the umbilicus, and an operating
arm was installed. A 5mm auxiliary operating hole was disposed downward between
the lens hole and the upper abdominal operating hole (Fig.23.1a).
(b) The affected side of the kidney is ectopic,
generally renal dysplasia accompanying
ectopic kidney, commonly in the pelvic cavity: children take the head low foot high
lithotomy position, all stressed parts are padded with sponge pad and xed with adhesive
tape. An 8 mm lens hole is placed at the
upper edge of the umbilicus (if patient is
young, the lens hole can be located 1–2cm
above the umbilicus), pneumoperitoneum is
established, two 8 mm operation holes are
disposed at 6cm on the left and right sides,
and a 5 mm auxiliary hole is placed above
the operating hole on the affected side and
the lens hole (Fig.23.1b).
D
Fig. 23.1 Trocar positions during robot-assisted nephrectomy. (a) Kidney in situ; (b) ectopic kidney. Point C is the posi-
tion of robotic camera port. Point A is the position of assistant port. Points 1 and 3 are the positions of two instrument ports
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C. Tao and L. Sun
23.5 Surgical Steps
Robot-assisted laparoscopic nephrectomy is
illustrated (taking renal dysplasia as an example)
(a) The lateral peritoneum and perirenal fascia
are opened at the lateral edge of the colon to
expose the kidney through the peritoneal path;
(b) Release renal vessels and ureter: look for the
ureter on the inside of the psoas major muscle, pick up the ureter to the outside, and
release its inner tissue to the lower part of the
renal pedicle. Release the renal pedicle and
expose its blood vessels;
(c) Separate all blood vessels in the renal pedi-
cle, ligate the proximal end of each vessel
with hemo-lok clip, then completely disconnect, and stop bleeding with an ultrasonic
knife or scissors;
(d) The ureter was lifted to the distal end and cut
at the level of the iliac vessels, and the distal
ureter was ligated with a hemo-lok clip;
(e) Release the residual adhesion between the
kidney and the surrounding tissue and completely cut off the kidney;
(f) Put 8 mm cannula or glove through 8mm
trocar, put the removed kidney into the bag,
pull out 8mm cannula or glove, expand the
hole, and pull out the bag. Attention should
be paid to avoid the kidney tissue remaining
in the abdominal cavity due to the damage of
air bag or gloves;
(g) Flush the renal fossa, check if there is
active bleeding, remove the abdominal
uid, place the pelvic drainage tube, count
the instruments, and remove the machine.
The skin incision was sutured, and the
operation was completed.
23.6 Technical Points andSkills
1. Because the abdominal cavity is narrow in
children, especially infants, it is very important to have a good posture placement, as well
as the design and establishment of the operation channel. Generally, the healthy lateral
decubitus position is 60–80°, so that the intraoperative exposure is good.
2. It is better that the abdomen of the child be
close to the edge of the bed and arms be
stretched forward and upward to create more
space for the manipulator arm. Because the
operation range of nephrectomy is large,
sometimes the ureter also needs to be removed,
so that the range of movement of the manipulator arm is also large. To avoid ghting
between the robotic arms during the operation, the distance between the two operating
holes should be greater than 6cm.
3. Because of the lack of force feedback and the
large clamping strength of the instruments, in
the early application of the Da Vinci system,
the clamping of tissues and organs such as
intestines or blood vessels should be minimized to avoid excessive mechanical bite force
and damage to organs and tissues. The double
ligation of hemo-lock and silk thread is more
reliable in the ligation of renal hilar vessels.
After the operation, renal fossa drainage is
helpful to observe postoperative bleeding.
23.7 Postoperative Complications
1. Hemorrhage is a common complication that
usually occurs within 24 h after surgery.
Hemorrhage is usually caused by injury to the
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159
renal vein, adrenal vein, or branching vessel.
Visceral injury (spleen, liver, intestine, or greater
omentum) and injury to large blood vessels can
also cause hemorrhage, but rarely, resulting in
serious complications and even death.
2. Other postoperative complications, including
retroperitoneal hematoma or abscess, wound
infection, pneumothorax, and incisional hernia, require timely detection and symptomatic
treatment. Retroperitoneal hematoma or
abscess and wound infection mainly need
strengthening anti-infection treatment, and
incision and drainage should be performed if
necessary. Closed thoracic drainage was performed when pneumothorax occurred.
3. Prevention and treatment of complications: in
all robotic surgeries, attention to detail and
observation of anatomical markers, especially
the large blood vessels and colon, can prevent
the most dangerous complications. It is easy
to over dissect the hilum in the treatment of
renal vessels in nephrectomy. However, the
dissection of renal vessels closer to the inferior vena cava is simpler, so over dissection of
the hilum should be avoided. To avoid heat
damage when separating the ventral kidney; it
should be noted that the colon and duodenum
are adjacent to the kidney. Thermal damage
from the use of a cautery device can result in
immediate or delayed intestinal perforation.
Control of the renal vein should be avoided
excessively close to the inferior vena cava to
handle the adrenal vein and reproductive vein
to prevent catastrophic massive bleeding.
23.8 Comparisons
withConventional
Laparoscopic Surgery
1. Compared with the traditional laparoscope,
the three-dimensional magnied eld of
vision of the robot system is clearer and has
higher resolution. This allows surgeons to
more accurately identify blood vessels in the
kidney during surgery without damaging
them [9].
2. Robot system: the highly exible robotic arm
system can complete difcult operations such
as grasping, holding, walking, hemostasis,
suturing, and ligation in a narrow space,
which cannot be achieved by laparoscopic
instruments and human hands. Moreover, the
robot system can lter the shaking of human
hands, reduce the fatigue of surgeons, and
reduce misoperation [10, 11].
3. There was no signicant difference in postop-
erative complications between laparoscopic
and robotic-assisted radical nephrectomy.
Robotic-assisted surgery costs more because
the cost of the instruments is higher than that
of traditional laparoscopic instruments
[12, 13].
4. The learning curve of the robot system for dif-
cult surgery is signicantly shorter than that
of traditional laparoscopy.
5. Bipolar coagulation and unipolar electrotome
can be used simultaneously in robot systems, which helps reduce perioperative
bleeding [14].
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23.9 Case Presentations and
Video
See Fig. 23.2.
C. Tao and L. Sun
D
Fig. 23.2 Procedures during robotic-assisted nephrectomy for kidney in situ. (a) Separation of kidney. (b–c) Ligation
of renal pedicle vessels. (d) Separation of ureter. (e) Ligation of ureter
References
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3. Gaur DD. Laparoscopic operative retroperitoneoscopy: use of a new device. J Urol. 1992;148:1137–9.
4. Koyle MA, Woo HH, Kavoussi LR. Laparoscopic
nephrectomy in the rst year of life. J Pediatr Surg.
1993;28:693–5.
5. Guillonneau B, Jayet C, Tewari A, et al. Robot assisted
laparoscopic nephrectomy. J Urol. 2001;166:200–1.
6. Gettman MT, Neururer R, Bartsch G, et al. AndersonHynes dismembered pyeloplasty performed using the
da Vinci robotic system. Urology. 2002;60:509–13.
7. Apelt N, Featherstone N, Giuliani S. Laparoscopic
treatment of intussusception in children: a systematic
review. J Pediatr Surg. 2013;48:1789–93.
8. Lee RS, Retik AB, Borer JG, et al. Pediatric robot
assisted laparoscopic dismembered pyeloplasty:
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comparison with a cohort of open surgery. J Urol.
2006;175:683–7.
9. Tasian GE, Casale P. The robotic-assisted laparoscopic pyeloplasty: gateway to advanced reconstruction. Urol Clin North Am. 2015;42:89–97.
10. Radmayr C, Bogaert G, Dogan HS, et al. EAU
Guidelines on Paediatric Urology. Eur urol.
2001;40:589–99.
11. Jeong IG, Khandwala YS, Kim JH, et al.
Association of Robotic-Assisted vs laparoscopic
radical nephrectomy with perioperative outcomes
and health care costs, 2003 to 2015. JAMA.
2017;318:1561–8.
12. Kim SJ, Barlog JS, Akhavan A. Robotic-assisted
urologic surgery in infants: positioning, trocar placement, and physiological considerations. Front Pediatr.
2019;6:411.
13. Emtage JB, Agarwal G, Sexton WJ. Roboticassisted renal surgery. Cancer Control.
2015;22:291–300.
14. Chiarenza SF, Bucci V, Zolpi E, et al.
Retroperitoneoscopic nephrectomy in pediatric patients. J Laparoendosc Adv Surg Tech A.
2021;31:1209–13.
F
Robotic-Assisted Pyeloplasty for
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Ureteropelopic Junction
Obstruction
ChangTao andHuixiaZhou
24
24.1 Introduction
Ureteropelopic junction obstruction (UPJO) is
a congenital ureteral abnormal disease caused
by various causes of stricture of the junction
between the renal pelvis and ureter and poor
urinary drainage, leading to various symptoms,
signs, and decline of renal function in patients,
with an incidence of 1/600–1/800 [1, 2]. The
main purpose of surgery is to remove the
lesion, relieve obstruction, relieve symptoms,
and protect renal function [3]. In the past, open
pyeloplasty has been regarded as the gold standard for the treatment of UPJO, but open surgery is traumatic, and recovery is slow. Since
Chuessler rst reported laparoscopic pyeloplasty in 1993, after more than 20 years of
development, many studies have conrmed
Supplementary Information The online version contains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_24.
C. Tao (*)
Department of Pediatric Urology, Children’s Hospital
of Zhejiang University School of Medicine,
Hangzhou, China
e-mail: dr.taoc777@zju.edu.cn
H. Zhou
Department of Urology, Bayi Children’s Hospital
Afliated of the Seventh Medical Center of PLA
General Hospital, Beijing, China
that compared with open pyeloplasty, laparoscopic pyeloplasty has the advantages of less
pain, less trauma, faster recovery, and better
cosmetic effect [4]. Moreover, the success rate
of surgery is no lower than that of traditional
open surgery. However, endoscopic suturing is
difcult to tie knots and has a long learning
curve, especially for children with limited
abdominal space, which requires more technical skills of the surgeon. The da Vinci robotassisted laparoscopic surgery system has a 3D
surgical perspective, and its robotic arm can
reach a range of 7° of freedom, which greatly
reduces the difculty of intramural anatomical
separation, suture and knotting, and other ne
operations [3, 5, 6]. The safety and effectiveness of robot-assisted laparoscopic pyeloplasty
have been demonstrated, and its success rate is
no lower than that of traditional laparoscopic
and open surgery [7].
24.2 Indications
andContraindications
Indications: at present, there are mainly the following points.
1. APD (anteroposterior diameter of the renal
pelvis) >30mm.
2. APD >20mm with dilatation of calyces.
3. Renal function <40% and T1/2>20min.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_24
161
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C. Tao and H. Zhou
4. Renal function decreased progressively during the follow-up period (decreased by more
than 5–10%).
5. Progressive deterioration of hydronephrosis
(one step increase in SFU grade or 10mm or
more in anterior and posterior diameter of
renal pelvis).
6. Symptoms related to hydronephrosis (pain,
repeated urinary tract infection, hematuria,
stones, etc.).
Contraindications: there are generally no
obvious contraindications to surgery unless
vital signs are unstable or there is abnormal
function of the heart, liver, lung and other
organs. Patients with poor nutritional status and
intolerance to anesthesia and pneumoperitoneum surgery. Relative contraindications
include underweight. (<5 kg), or younger than
1 month. However, if you’re a skilled surgeon
you can explore.
Bowel preparation included cleansing enema
24 hours before surgery, fasting for 8 hours and
being water-free for 2 hours before surgery.
Preoperative antibiotics should be administered intravenously 30 minutes before
surgery.
Depending on the half-life of the selected antibiotics and the length of surgery, the drugs can be
administered intraoperatively to ensure that the
effective concentration of drugs covers the entire
procedure. Urinary catheters and gastric tubes
were used before the operation.
For patients with unclear diagnoses, preoperative cystoscopy catheterization and retrograde
pyelography were used to determine the location
of the obstruction (Fig. 24.1).
24.3 Preoperative Preparation
If there is a urinary tract infection, control the
infection for 2 weeks before surgery.
Laboratory tests included routine hematuria,
coagulation function, liver and kidney function,
etc. Imaging tests include abdominal and urinary
B-ultrasound, VCUG, MRU, ECT, etc. No operation contraindications were found after anesthesia consultation.
Fig. 24.1 Retrograde pyelography showed the location
of obstruction
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24.4 Position andDocking
The patient was placed in the healthy side lateral decubitus position (the height of the affected
side pad was 45–80°), the abdominal wall was
placed close to the bed, the affected side upper
limb was placed in the natural pendent position,
and the healthy side upper limb was abducted
and supported by the hand plate. The healthy
side of the lower extremity is exed, and the
affected side of the lower extremity is slightly
backward and downward exed. All the stressed
parts are padded with sponge pads, and if necessary, warm air heaters are used for insulation,
and tapes or bandages are used for xation
(Fig.24.2).
Fig. 24.2 Layout of the trocar for robotic-assisted laparoscopic pyeloplasty. An 8-mm lens was inserted
through the umbilicus (point C) to establish pneumoperitoneum, and the pneumoperitoneum pressure was
maintained at 8-12 mmHg (1 mmHg= 0.133 kPa).
Under direct vision, an 8 mm operation channel (No. 2
instrument arm) was inserted at the intersection of the
superior margin of the pubic symphysis and the abdominal transverse stria. A 5 mm (or 3 mm) auxiliary hole
operation channel was placed in the upper abdomen of
the healthy side 3 cm away from the lens arm (point A),
and an 8 mm operation channel (No. 1 instrument arm)
was placed under the xiphoid processes descending to
the affected side. The distance between the two robotic
arms was no less than 6 cm (the distance between the
operation hole of the two instrument arms and the lens
hole was basically the same). The intake of the pneumoperitoneum tube should be replaced with the auxiliary
hole, and the laparoscopic lens should be 30°
downward
24.5 Surgical Steps
24.5.1 Determination theLesion Site
An electric shear is used to open the peritoneum
on the lateral side of the colon and push the colon
inward (paracolonic approach). Alternatively, the
mesenteric window was opened (left mesenteric
approach) (Fig. 24.3a) along the lower margin of
the inferior mesenteric vein, the medial margin of
the descending colon, the lateral margin of the
spermatic vein, and the avascular area of the
upper margin of the left colonic artery. The renal
pelvis and upper ureter were dissociated and
exposed, and the location and cause of obstruction were determined (Fig. 24.3b).
24.5.2 Operation ofPyeloplasty
The dilated renal pelvis was cut in an arc, the
upper pole of the renal pelvis was pulled by a
traction line through the abdominal wall
(Fig.24.3c), and the narrow segment of the ureter
was excised. The lateral wall of the ureter was
longitudinally cut for about 2.0cm (Fig. 24.3d),
the lowest point of the renal pelvis (Fig. 24.3e)
and the lowest split point of the ureter were
sutured with a 6-0 absorbable line, and the posterior wall of the anastomosis was sutured continuously or discontinuously. Double J tubes were
placed anterograde at the anastomosis (different
types were selected according to the age and
height of the child) (Fig. 24.3f). Double J showed
stained urine outow, indicating that the end had
entered the bladder (Fig. 24.3g). The anterior
wall of the anastomosis and the extra opening
pelvis were continuously sutured (Fig. 24.3h).
24.5.3 Indwelling Drainage Tube
andClosing Incision
After rinsing the wound with warm normal saline,
the abdominal effusion was washed and no active
bleeding was conrmed in the operative eld. The
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C. Tao and H. Zhou
e
f
ghi
Fig. 24.3
(b) The UPJ was dissociated and exposed. (c) The renal
pelvis was pulled by traction. (d) The ureter was longitudinally cut for approximately 2.0 cm. (e) The rst stitch
Surgical steps. (a) Left mesenteric approach.
and the lowest point of the renal pelvis (according to the
lowest calyces). (f) Placement of double-J tubes. (g)
Showed stained urine outow. (h) The anterior wall of the
anastomosis. (i) Closure of the defective peritoneum
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165
peritoneum or mesenteric window was sutured intermittently with a 5-0 absorbable line (Fig. 24.3i), the
operating instruments of each robotic arm were
withdrawn, the drainage tube was placed from the
umbilical incision at the lowest part of the pelvic
cavity under direct view, the pneumoperitoneum
was closed, the operation channels were withdrawn,
the peritoneum and the incision were sutured, and
the skin edge was glued with medical adhesive.
24.6 Technical Points andSkills
If the pelvis is too small and the exposure is
barely satisfactory, the ureter may be exposed
rst. Avoid excessive dissociation of the ureter
and pay attention to protecting the inner side of
the ureter. Otherwise, poor vascular anastomosis
will affect healing and even urine extravasation.
The renal pelvis should be irrigated several
times before closure to avoid retention of blood
clots and tissue residue resulting in obstruction
and poor drainage.
Proper traction improves the efciency of
exposure, dissection, and anastomosis.
Do not cut too much tissue, which will lead to
excessive tension of anastomosis.
24.7 Postoperative Complications
1. Complications related to the establishment of
operating channels: the abdominal wall is
thin, and the abdominal cavity is small in children. When establishing pneumoperitoneum
or trocar puncture into the abdominal cavity,
the abdominal vessels, intestine, diaphragm,
pleura and substantial internal organs in the
abdominal cavity may be accidentally injured.
Once injury is found, suture and repair damaged blood vessels or tissue in time.
2. Complications related to robotic arms and
electrosurgical instruments: When the robotic
surgeon is not at the bedside of the patient, he
or she cannot notice whether the manipulator
and the instrument arm contact and collide
with the patient in vitro when operating on the
operating table of the robotic surgeon. For
example, improper positioning and operation
channel design can easily cause compression
and collision injuries. Good posture placement, operation channel design and close
cooperation between assistants can avoid such
complications. Robotic surgery relies more on
special instruments to complete various operations in the body cavity. When using these
instruments, complications may occur if
improper operation or instrument failure
occurs. Be familiar with electrosurgery, perform surgical operations under direct vision,
pay attention to the distinction and boundary
between the heat conduction surface and insulation surface, and repair normal tissue immediately once found or suspected.
3. Hematuria: Postoperative hematuria is mostly
caused by postoperative residual blood drainage or internal stent tube stimulation.
Conservative observation and treatment, such
as full uid replenishment, drinking more
water and less activity, can improve. In cases
of excessive bleeding, anastomosis or renal
pelvis bleeding should be considered, the
amount of uid rehydration can be appropriately increased, and hemostatic drugs should
be given to prevent or treat hematuria.
Children with severe gross hematuria should
be closely observed. In case of urinary duct
blockage, timely ushing or replacement
should be performed to keep catheter drainage
unobstructed. Meanwhile, changes in hemoglobin should be closely monitored.
4. Low back pain and urinary tract irritation are
generally caused by internal stent tube stimulation or poor drainage, and adequate uid
rehydration to ensure urine volume and reduce
activity can alleviate the above symptoms.
When necessary, anticholinergic drugs can
alleviate the above symptoms, and 4-8 weeks
after the removal of the double-J tube can
relieve them. Prevention: Intraoperative double-J tubes of appropriate type and length
were selected according to the height of the
child to maintain unobstructed internal
drainage.
5. Anastomotic leakage is the most common
complication after pyeloplasty and is usually
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