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Fig. 26.2 Surgical procedures. (a) Bladder traction. (b)
Exposing the surgical area behind the bladder. (c)
Mobilize prostatic utricle cyst. (d) The anatomic relationship between vas deferens and prostatic utricle cyst. (e)
Transection of the top of prostatic utricle cyst. (f) Full
mobilization of the main body of the cyst. (g) Transection
of the neck of prostatic utricle cyst. (h) Suture was started
at 6 o’clock. (i) Suture each half circle. (j) Tied at 12
o’clock. (k) Pelvic drainage and closure of the broken
peritoneum
J
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LM N
Fig. 26.2 (continued)
K
26.6 Technical Points andSkills
1. Preoperative cystoscopy showed that there
was no cervical structure in the prostatic
utricle cyst. If there was any cervical structure, it was mullerian duct residue. Simply
excision of prostatic utricle cysts can be
performed.
2. The bladder was drawn and the operative area
was fully exposed. A tube can be placed in the
cyst during cystoscopy, and uid can be
injected to enlarge the cyst if necessary, which
can help identify the structure of the cyst.
3. Pay attention to heat injury during sugery and,
avoid injury to the accessory pudendal artery,
which may lead to adult erectile dysfunction,
4. Make clear the position of the bilateral vas
deferens into the prostatic utricle cyst, keep at
least 0.5cm of residual end when cutting the
top of the cyst, and pay attention to avoid
damaging the vas deferens, rectum, and
ureter.
5. The edge of the proximal and distal stump of
the prostatic utricle cyst should be left at least
0.5–0.7 cm for suturing, and 6-0 Biosyn
suture should be used to meet the balance of
tension and absorption time.
6. Give attention to the exible function of the
robot wrist. Sutures can be used to sew half a
circle continuously from 6 o’clock and tie a
knot at 12 o’clock.
26.7 Postoperative Complications
1. Digestive system complications of rectal
injury occur in free bleeding and unclear eld
of vision, so the separation should be strictly
hemostasis; in case of injury, remove the contaminated tissue around the wound, suture the
damaged area in two layers, and wash a lot
with antibiotics.
2. Ureteral bladder injury often occurs when the
posterior wall of the bladder is separated,
especially when the rectum depression perito-
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neum reex incision is too high. Double-J
tubes should be placed during treatment, and
the damaged parts should be sutured and
repaired.
3. Urethral stricture may be caused if the prostatic utricle cyst neck is excised too low.
Intraoperative repair, indwelling catheterization for 2weeks, and cystoscopy for expansion are done if necessary.
4. Repeated urinary tract infection is a common
complication. Drainage is unobstructed.
Strengthened anti-inammatory can minimize urinary tract infection.
5. Vas deferens atresia caused by injury, scar
adhesion, inammation, and infection can be
intervened in adults.
26.8 Comparisons
withConventional
Laparoscopic Surgery
Compared with traditional laparoscopic surgery,
robotic surgery has congenital technical advantages, because of its precise surgical operation
damage, so that the removal of prostatic utricle
cyst can be performed at the same time as seminal reconstruction. There have been no reports of
similar operations using laparoscopic techniques.
The pelvic operation space is relatively small,
and robotic surgical wrist instruments can be
exibly used in this space. In addition, the direction of anastomosis is parallel to the long axis of
the human body. Traditional laparoscopic anastomosis is often difcult, the quality of the anastomosis is not high, and the relative complications
will increase. However, robotic surgery can overcome this shortcoming, so it can also shorten the
hospital stay of patients. The main disadvantage
of robotic surgery is the high cost, usually three
times that of traditional laparoscopic surgery [9].
At present, due to the limited number of cases of
this type of surgery, there is a lack of evidence to
support that the long-term effects of robotic surgery due to traditional laparoscopic surgery.
References
1. Hester AG, Kogan SJ.The prostatic utricle: an underrecognized condition resulting in signicant morbidity in boys with both hypospadias and normal external
genitalia. J Pediatr Urol. 2017;13:492.e1–5.
2. Ferong K, Waterschoot M, Sinatti C, etal. Rare and
special robotic surgery indications in the pediatric
population: ectopic organs and differences of sexual
development. World J Urol. 2020;38:1865–8.
3. Liu B, He D, Zhang D, Liu X, etal. Prostatic utricles
without external genital anomalies in children: our
experience, literature review, and pooling analysis.
BMC Urol. 2019;19:21.
4. Mostafa IA, Woodward MN, Shalaby
MS. Cystoscopic-assisted laparoscopic excision of
prostatic utricle. J Pediatr Urol. 2018;14:77–8.
5. Waterloos M, Ploumidis A, Pappas A, De Bleser E, De
Groote R, Weyers S, etal. Robot-assisted resection of
ectopic kidney in children: an anatomical illustration.
J Pediatr Urol. 2018;15:87–8.
6. Claeys T, Denys MA, Waterloos M, et al. Robotassisted laparoscopic resection of pelvic embryologic remnants: illustration with a prostatic utricle.
Videourology. 2018;32:6.
7. Cave J, Clarke S.Pediatric robotic surgery a review of
the current status of robotic surgery use in paediatrics.
Ann R Coll Surg Engl. 2018;100(Suppl 7):18–21.
8. Rowe CK, Pierce MW, Tecci KC, Houck CS, Mandell
J, Retik AB, etal. A comparative direct cost analysis
of pediatric urologic robot-assisted laparoscopic surgery versus open surgery: could robot-assisted surgery
be less expensive? J Endourol. 2012;26:871–7.
9. Macedo A Jr, di Migueli RDD, etal. Robotic-assisted
excision of a prostatic utricle cyst in a 12-month boy
with proximal hypospadia and 45X0/46XY karyotype.
J Pediatr Urol. 2020;16:725–6.
Robot-Assisted
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Ureteroureterostomy for
Duplicated Kidneys
GuangjieChen andHuixiaZhou
27
27.1 Introduction
Ureteroureterostomy was rst used for the treatment of duplicated kidneys and ureters. It has
been reported that the incidence rate of duplication of the kidneys and ureters in children is
approximately 2%. Due to its special pathological anatomical structure, most patients have urinary incontinence, recurrent urinary tract
infections (UTIs), and decreased renal function
[1, 2]. There are various surgical plans for duplicated kidneys and ureters, among which ureteroureterostomy is a commonly used surgical
procedure. However, open ureteroureterostomy
has disadvantages of more trauma, more intraoperative loss of blood, and longer hospital stay
time. Laparoscopic surgery is difcult for beginners because of the long learning curve and
Supplementary Information The online version contains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_27.
higher technical requirements for the surgeon.
With the upgrading of robotic surgical systems,
the robot- assisted laparoscopic ureteroureterostomy has gradually been recognized by pediatric
urologists, due to its advantages, such as ne
operation and stability [3]. This chapter will provide an overview of pediatric robot-assisted laparoscopic ureteroureterostomy.
27.2 Indication andContradiction
Indications: duplicated kidneys with symptoms
such as recurrent UTIs, urinary incontinence, or
pain. Progressive aggravation of hydronephrosis
and decreased renal function. Radionuclide
renogram shows that the affected kidney is still
worth preserving [4].
Contradictions: uncontrolled pyonephrosis
status; the affected moiety is nonfunctional or the
renogram is not developed [4].
27.3 Preoperative Preparation
G. Chen (*)
Department of Pediatric Urology, Children’s Hospital
of Zhejiang University School of Medicine,
Hangzhou, China
e-mail: dr.chenguangjie@zju.edu.cn
H. Zhou
Department of Urology, Bayi Children’s Hospital
Afliated of the Seventh Medical Center of PLA
General Hospital, Beijing, China
© 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_27
(a) Detailed history collection and physical
examination: including renal diseases or
amniotic uid abnormalities are found during the fetal period, recurrent febrile UTIs,
urinary incontinence that cannot be relieved,
and perineal physical examination (female
patients) that reveals ectopic ureteral
opening
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G. Chen and H. Zhou
(b) Laboratory tests: routine blood and urine
tests, liver and kidney function, electrolytes,
blood glucose, and coagulation function.
Bacterial culture and drug sensitivity tests
are required for coinfected patients
(c) Imaging examinations: The presence of uri-
nary tract dilation, ureteral cysts, and ectopic ureteral openings could be detected by
urinary tract ultrasound and magnetic resonance urography. ECT examination should
be performed to obtain the renal function
and determine whether to undergo nephrectomy and ureterectomy on the affected
side. Voiding cystourethrography (VCUG)
examination should be performed to understand the presence of the lower pole system
vesicoureteral reux (VUR), and the anastomosis of the upper pole ureter to the
lower pole ureter should be avoided when
VUR exists
(d) Preoperative medication adjustment: UTIs
should be controlled before the operation,
and broad-spectrum antibiotics are recommended to be prophylactically used 30 minutes preoperatively to reduce the risk of
infection.
(e) Fasting semi-uid for 6 hours before surgery,
water forbination for 2 hours before surgery,
skin preparation, catheterization, preoperative sterilization, blood preparation, and correction of severe anemia and water and
electrolyte disorder. Surgical instruments
include selecting the matching operating
instruments according to the size of the child,
and routinely equip ping them with ultrasonic knives or LigaSure.
27.4 Position andDocking
Position
(a) After anesthesia, the lithotomy position was
taken rst, and a double-J stent was indwelt
into the lower pole ureter through
cystoscopy.
(b) Then, the patient was placed in the supine
position, the affected side was padded, and
the patient was xed.
Port Placement
(a) An 8 mm lens was inserted around the umbili-
cus to establish pneumoperitoneum and maintain a pressure of 8–10 mmHg (Fig. 27.1).
(b) Two 8 mm operating holes were placed
above and below the umbilicus. The distances between the two holes and the umbilical are equal, ensuring that the distance
between the two holes ≥ 6 cm.
(c) A 5 mm auxiliary operating hole was placed
on the midline between the above operating
hole and the lens hole.
27.5 Surgical Procedure
(a) Ureteral dissection
Intraoperative X-ray imaging will be useful to
conrm the stent placement if the surgeon is
concerned about the location of the distal end
of the double-J stent. The peritoneum is then
incised medial to the spermatic cord and above
the vas deferens (the girl is medial to the ovarian vessels and above the ovary at the pelvic
cavity). The dilated ureter of the upper kidney
and the normal ureter of the lower kidney were
exposed. The upper ureter was dissociated
downward at pelvic level, and the excess upper
ureter was transected (Fig. 27.2a, b).
(b) Anastomosis
End-to-side anastomosis was performed
after the upper ureter was transected. A longitudinal incision was made on the recipient
ureter with a length of about 1–1.5 cm.
Absorbable sutures of 5-0 and 6-0 cm are
recommended for use in elderly children and
infants, respectively (Fig. 27.2c, d). The
color of the suture could be easily identied.
The donor ureter could be drawn with a 2-0
suture if necessary, which was indwelt
through the abdominal wall.
(c) Ureteral stump dissection
Resection of the pelvic ureteral stump is difcult during open ureteroureterostomy. The
visual eld is good during robot-assisted laparoscopic surgery and can be magnied 10
times, which is conducive for the resection of
ureteral stump. The upper ureter was com-
cd
27 Robot-Assisted Ureteroureterostomy for Duplicated Kidneys
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181
Fig. 27.1
ureteroureterostomy. Point C is the position of robotic
camera port. A is the position of assistant port. Points 1
and 2 are the positions of two instrument ports
Trocar positions during robot-assisted
a
Fig. 27.2 Surgical procedure. (a) Exposing the dilated upper pole ureter. (b) Dissecting the upper pole dilated ureter.
(c) Tailor ureters and preparepreparation for anastomosis. (d) Anastomosis between two ureters
b
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G. Chen and H. Zhou
pletely released and disconnected close to the
bladder. The ureteral stump should be sutured
and ligated if vesicoureteral reux exists; otherwise, the stump can be left open. It is
important to avoid damaging the lower ureter.
Moreover, attention should be paid on protection of the vas deferens and the fallopian tube
or ovarian for male and female patients,
respectively. In addition, an excessive release
of the ureter may impact the function of urinary control, especially when the ureter is
abnormally opened in the bladder neck [5].
27.6 Technical Points and Skills
(a) The peritoneum is incised medial to the sper-
matic cord and above the vas deferens (the
girl is medial to the ovarian vessels and
above the ovary). Pay attention to the protection of gonads and gonadal vessels.
(b) The longitudinal incision of the recipient
ureter was selected at the entrance of the
brim. The position is shallow, and it is easy
to anastomose. If the incision selection is too
low, it may lead to difcult anastomosis.
(c) The incision length of the lower ureter is
consistent with the diameter of the upper ureter. The ureter needs to be tailored if its
diameter is >1.5 cm, which could be performed in the abdominal cavity or by pulling
it out from the auxiliary hole.
(d) The recipient ureter should be dissociated as
little as possible to reduce the damage to the
ureteral blood supply, which may cause anastomotic stenosis. Because the ureter of this
area is relatively xed, it can be easily anastomosed without traction during the operation.
Procedures such as clamping of the ureter
should be avoided to minimize injury.
27.7 Postoperative Complications
27.7.1 Urine Leakage
Urine leakage stimulates the posterior peritoneum, causing symptoms such as intestinal
obstruction, malignancy, vomiting, and abdominal pain. Ultrasound examination can indicate a
urinary cyst or uid accumulation around the
anastomotic eld, while a small amount of uid
accumulation may also exist in the early postoperative period. Complete resection of the
obstructed upper ureter can reduce the ureteral
tension during anastomosis, enabling tensionfree anastomosis possible. Fine anastomosis of
the mucosa-to-mucosa can reduce the risk of
urine leakage. “Indigo carmine” can be used to
check if there is urine leakage after the anastomosis. The placement of ureteral stents can
reduce the risk of urine leakage. If urine leakage
persistently exists when the ureteral stent is
clear, percutaneous nephrostomy may possibly
be performed. If the above-mentioned methods
do not work, reoperation needs to be
considered.
27.7.2 Structure
Fine operation of tissue and reasonable use of
electrocautery enable the tension-free ureteral
anastomosis, which could reduce the occurrence
of anastomotic stenosis. It should be noted that if
the stenosis occurs at the Y-shaped anastomosis,
it will affect function of both the upper and lower
kidneys. In addition, it is still controversial
whether the ureteral diameter differences affect
the success rate of surgery; however, some
researchers consider that the size of the ureteral
diameter is not the key factor affecting the success rate of surgery [6].
27.7.3 Ureteral Stump Symptoms
Clinical manifestations were abdominal pain and
urinary tract infection if the ureteral stump
existed persistently. VCUG should be performed
routinely before operation in order to exclude
vesicoureteral reux. To reduce the stump infection and reoperation rate, the stump should be
resected as much as possible. The ureteral stump
was cut off and ligated in the case of reux or left
open if reux was absent [7].
27 Robot-Assisted Ureteroureterostomy for Duplicated Kidneys
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183
27.8 Comparisons
withConventional
Laparoscopic Surgery
At present, there are few studies comparing RUU
and laparoscopic ureteroureterostomy for ureteral anastomosis. Some studies have indicated
that RUU has some advantages in terms of hospital stay, recovery time, and suture time, but no
obvious advantages in the rates of postoperative
complications and recurrence [8, 9].
Currently, the effect of RUU has been conrmed by short-term postoperative follow-up.
RUU has more advantages than open surgery in
the management of ureteral stumps. However,
tissue management during robotic surgery is
different from that during open surgery, so longterm continuous postoperative follow-up is still
needed to evaluate the long-term surgical effect
[10].
Surgical cost is an inevitable problem for
robotic surgery, possibly because the fact that
robotic surgery is not cost-effective due to its
high xed costs. However, robotic surgery could
become more cost-effective if hospital stays are
signicantly reduced compared to standard
open surgery [11]. To the authors' knowledge,
no studies have analyzed the specic costs of
RUU in children. In the future, as more robot
manufacturers enter the market, the cost of
robotic surgery may decrease.
Currently, there is some debate about whether
robotic platform surgery is suitable for pediatrics. Robot-assisted pyeloplasty has been widely
used in children and has been shown to have the
same high success rate and shorter hospital stay
as open surgery. The results of this procedure
are acceptable, but the additional cost of the
procedure is a problem [12, 13]. However, for
ureteral replantation surgery, relevant reports
show that compared with open surgery, robotassisted ureteral replantation has more complications, a lower success rate, and a higher
surgical cost [14]. The choice of robotic platform surgery needs to be case-by-case, and
some patients, such as older children or obese
patients, may benet more from a minimally
invasive approach. It is important for pediatric
urology to explore suitable indications for
robotic surgery.
27.9 Case Presentations
and Video
References
1. Kawal T, Srinivasan AK, Talwar R, et al. Ipsilateral
ureteroureterostomy: does function of the obstructed
moiety matter? J Pediatr Urol. 2019;15:50. e1–50. e6.
2. Wong NC, Braga LH. Open ureteroureterostomy for
repair of upper-pole ectopic ureters in children with
duplex systems: is stenting truly necessary? J Pediatr
Urol. 2019;15:72. e1–72. e7.
3. Lee NG, Corbett ST, Cobb K, etal. Bi-institutional
comparison of robot-assisted laparoscopic versus
open ureteroureterostomy in the pediatric population.
J Endourol. 2015;29:1237–41.
4. Wyatt RA, James ST, Canon SJ, et al. Hydronephrosis
and Hydroureter Improvement Rates in RoboticAssisted Laparoscopic Uretero-Ureterostomies:
Does Anastomotic Site Matter? Urology.
2021;158:180–3.
5. Abdelhalim A, Chamberlin JD, Truong H, et al.
Ipsilateral ureteroureterostomy for ureteral duplication anomalies:predictors of adverse outcomes. J
Pediatr Urol. 2019;15:468. e1–468. e6.
6. Harms M, Haid B, Schnabel MJ, et al.
Ureteroureterostomy in patients with duplex malformations: does a large diameter of the donor ureter
affect the outcome? J Pediatr Urol. 2019;15:666.e1–6.
7. Cezarino BN, Lopes RI, Berjeaut RH, et al. Can
extended upper pole ureterectomy prevent ureteral
stump syndrome after proximal approach for duplex
kidneys? Int Braz J Urol. 2021;47:821–6.
8. Fuchs ME, DaJusta DG. Robotics in Pediatric
Urology. Int Braz J Urol. 2020;46:322–7.
9. Sun G, Yan L, Ouyang W, et al. Management for
Ureteral Stenosis: A Comparison of Robot-Assisted
Laparoscopic Ureteroureterostomy and Conventional
Laparoscopic Ureteroureterostomy. J Laparoendosc
Adv Surg Tech A. 2019;29:1111–5.
10. Villanueva CA. Open vs robotic infant ureteroureterostomy. J Pediatr Urol. 2019;15:390. e1-390. e4.
11. Elizondo RA, Au JK, Song SH, et al. Open versus robot-assisted laparoscopic ureteral reimplantation: Hospital charges analysis and
outcomes at a single institution. J Pediatr Surg.
2020;9:S0022-3468(19)30901–7.
12. Esposito C, Cerulo M, Lepore B, et al. Roboticassisted pyeloplasty in children: a systematic review
of the literature. J Robot Surg. 2023; Epub ahead of
print.
184
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G. Chen and H. Zhou
13. Andol C, Adamic B, Oommen J, Gundeti MS.
Robot-assisted laparoscopic pyeloplasty in infants
and children: is it superior to conventional laparoscopy? World J Urol. 2020;38:1827–33.
14. Kurtz MP, Leow JJ, Varda BK, et al. Robotic versus open pediatric ureteral reimplantation: Costs
and complications from a nationwide sample. J
Pediatr Urol. 2016;12:408. e1–408. e6.
Robotic-Assisted Adrenal Tumor
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Resection
JinhuWang andJiabingCai
28
28.1 Introduction
Adrenal tumors are the most common retroperitoneal tumors in children. Neuroblastoma is the
most common pathological type, and lesions
such as pheochromocytomas, adrenal cortex
neoplasms and adrenal cysts are also found in
this age-group [1, 2]. Neuroblastoma accounts
for about 10% of solid tumors in children, and
about 70% of them originate from the adrenal
gland. Since the biological behavior of neuroblastoma is characterized by early lymphatic and
hematogenous metastasis, most patients have
vascular encased and distant metastasis at the
time of presentation. However, there is also a
proportion of patients whose tumors are diagnosed to be conned to the adrenal area, and in
these patients, minimally invasive surgery can be
performed. Several studies have found that laparoscopic adrenal tumor resection in cases without image- dened risk factors (IDRF) is safe and
feasible [3–7]. However, after the peritoneal
Supplementary Information The online version contains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_28.
J. Wang (*) · J. Cai
Department of Oncology Surgery, Children’s
Hospital, Zhejiang University School of Medicine,
Hangzhou, China
e-mail: wjh@zju.edu.cn
adrenal area is a small area composed of liver
and kidney or spleen and kidney, and the tumor
is often clinging to the inferior vena cava or
abdominal aorta, this minimally invasive surgery
presents a great challenge to surgeons. After the
birth of the surgical robot, it soon showed obvious advantages with the exibility and precision
of its robotic arm, making the minimally invasive resection of adrenal tumors safer and easier
[8–10].
28.2 Indications
andContraindications
The da Vinci technique can theoretically be
applied to all adrenal tumors without
IDRF.However, we must pay attention to the following points. First, since a large part of adrenal
neuroblastoma in small infants, especially neonates, tends to spontaneously regress, surgery is
not the rst choice of treatment, and only patients
with tumor progression during close clinical
observation need surgery. Second, if the tumor is
too large, it may increase the risk of tumor rupture, but a diameter of more than 5cm is not an
absolute contraindication to robotic surgery. The
ratio of tumor volume and abdominal cavity
space is more important, as long as there is
enough exposure space, robotic surgery is feasible [8].
Adrenal tumors with IDRFs are contraindi-
cated for robotic surgery.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
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