Robotic-Assisted Urologic Surgery Techniques for Children

Q&A with pediatric urologist

Young boy blowing bubbles

Pediatric urologist Jonathan C. Routh, MD, MPH, started Duke’s pediatric robotic program in 2011 and is one of only a few pediatric urologists in the Southeast who regularly performs complex pediatric robotic-assisted surgeries, a technology more commonly used in adult urology. In this Q&A, he discusses how robotic techniques are adapted for children and how they help children recover more quickly than they do from traditional open surgeries.

Q: Why has robotic-assisted surgery for children been slow to be adopted?

Routh: The main reason is that we have less “working space” in children than adults, making minimally invasive robotic-assisted surgeries more technically challenging. There’s lots of room to work in an adult, but because of the limited environment in a child, we’ve had to adapt robotic techniques to keep children’s delicate tissues safe from the instruments. Because it’s so challenging, not many urologic surgeons are using it for children. At Duke, we perform 20 to 25 robotic-assisted surgeries for children every year, using the most advanced da Vinci Xi system (Intuitive Surgical, Inc., Sunnyvale, CA). I have specialized training in robotics and minimally invasive surgery, and I try to perform as many of those types of surgeries as possible in order to help kids get out of the hospital and back to their usual activities faster.

Q: Why are robotic-assisted urologic surgeries beneficial for children?

Routh: In the past, the only option to treat children with urologic diseases was with open surgery. Because these incisions are painful, recovery (both in the hospital and later at home) was a slow process. Rather than making a big incision in a child, robotic-assisted surgeries allow us to make smaller ones, so children bounce back more quickly and get back to their usual, pain-free activities faster than was previously possible.

Q: How do you make robotic techniques commonly used in adults more “child-friendly”?

Routh: One way is to minimize the number of incisions; we don’t use multiple “assistant” robotic ports that are often used for adult surgery, since that means another incision. We are also big proponents of hiding incisions differently in children than adults. Whenever possible I use a hidden incision endoscopic surgery approach, which places the ports in locations below the underwear line, where a child won’t see the scars later in life.

Q: What is the most common pediatric urologic condition you treat with robotic technology?

Routh: The most common is robotic pyeloplasty, in which we unblock an obstructed kidney and reroute urine to a normal flow pattern. Traditionally, the procedure was performed as an open surgery through a 6- to 8-inch incision in the patient’s flank. Robotic pyeloplasty has success rates equal to that of open surgery but with less postoperative pain, a shorter hospital stay, earlier return to normal activity, and a better cosmetic result. It’s a permanent solution for the obstruction, and children typically go home the next day.

Q: Do you only use robotic techniques for pediatric urologic surgeries?

Routh: No, that’s just one tool we use. The bottom line is, I want to do the least invasive surgery for a child that will accomplish our goal of finding a way to help the child grow up happy, healthy, and pain-free. Sometimes that requires an open approach, sometimes a robotic-assisted approach, and sometimes it requires no surgery at all—observing rather than operating. Robotics are ‘whiz-bang’ technology and fun to talk about, but at the end of the day, our focus is squarely on each individual patient.   Since no two children are exactly alike, we always individualize the treatment to each child in order to use the best tool possible to get them to their ultimate goal. Our job as pediatric urologists is to make sure that the right child gets the right treatment at the right time, and robotic-assisted surgery is and will continue to be a huge help in that regard.