ENDOUROLOGY & LAPAROSCOPY

Robot assisted laparoscopic partial nephrectomy: a viable and safe option in children
Lee RS, Sethi AS, Passerotti CC, Retik AB, Borer JG, Nguyen HT, Peters CA
Department of Urology, Children’s Hospital Boston, Boston, Massachusetts, USA
J Urol. 2009; 181: 823-8; discussion 828-9

• Purpose: The safety, benefits and usefulness of laparoscopic partial nephrectomy have been demonstrated in the pediatric population. We describe our technique, and determine the safety and feasibility of robot assisted laparoscopic partial nephrectomy based on our initial experience.
• Materials and Methods: We retrospectively reviewed robot assisted laparoscopic partial nephrectomy performed at our institution between 2002 and 2005. The technique was conducted via a transperitoneal approach with the da Vinci Surgical System using standard laparoscopic procedural steps. Clinical indicators of outcomes included estimated blood loss, complications, in hospital narcotic use and length of stay.
• Results: Robot assisted laparoscopic partial nephrectomy was completed successfully in 9 cases. Mean patient age was 7.2 years and mean follow-up was 6 months. Mean operative time was 275 minutes and mean estimated blood loss was 49 mL. Operative times improved significantly with experience. Overall patients had a mean hospitalization of 2.9 days and required 1.3 mg morphine per kg. All patients had a normal remaining renal moiety confirmed on Doppler ultrasound. The only complication was an asymptomatic urinoma discovered on ultrasound, which was treated with percutaneous drainage and ultimately resolved.
• Conclusions: Our initial experience shows the safety and feasibility of robot assisted laparoscopic partial nephrectomy in children. Operative time decreases with experience. The enhanced visualization and dexterity of a robotic system potentially offer improved efficiency and safety over standard laparoscopy. Robot assisted laparoscopy is an option for partial nephrectomy and may become the minimally invasive treatment of choice.
  
  
• Editorial Comment
  This report on robotic assisted laparoscopic partial nephrectomy in the pediatric population is another pioneering manuscript that raises the everlasting question of minimally invasive surgery in children and the true benefits that this treatment modality offers. Another similar major query is the advantage of robotic surgery versus standard laparoscopic procedure.
  The later would allow the surgeon to reach the lowest more distal ureteral cuff when performing the ureterectomy to prevent stump infection and other complications, with ease without docking and docking the robot to re-position the patient. Cost is also a major consideration since the economics of health care has been influencing somewhat how we practice medicine today. These issues do not take any merit from the authors that developed a very nice minimally invasive approach to a common pediatric dilemma with minimal complications.

Dr. Fernando J. Kim
Chief of Urology, Denver Health Med. Ctr.
Assistant Professor, Univ. Colorado Health Sci. Ctr.
Denver, Colorado, USA
E-mail: fernando.kim@uchsc.edu