Milestones in Minimally Invasive Surgery in CHOP Pediatric Urology

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Urology Update

About a year ago, pediatric urologic surgeons in Children’s Hospital of Philadelphia (CHOP) completed their 1,000th robotic reconstructive procedure in a child. There was not much fanfare or celebration but we all felt a quiet sense of a remarkable milestone — a sense of accomplishment for successfully bringing a minimally invasive approach for reconstruction to a broader group of patients who get the most from this technique: Children.

Laparoscopy: Advances and innovations

Laparoscopic procedures in pediatric urology have been performed in children since 1993. Since this time, pediatric urologists at CHOP have performed thousands of laparoscopic procedures. Procedures have ranged from straightforward inguinal hernia repairs and orchiopexy to complex procedures like retro-peritoneal lymph node dissections (RPLND) for testicular cancer, partial nephrectomy for renal tumors, nephrectomy, calyceal diverticulectomy and renal cyst ablation.

Procedures have evolved from a more traditional three-port approach to the state-of-the-art “single-site laparoscopy” where three instruments are inserted through a single port in the umbilicus, a point of easy access to the peritoneal space. Single-site laparoscopy is quicker to heal from and essentially scar-less as the entire incision is in the umbilicus. We are the only pediatric urological group in the country to offer this modality of treatment for this broad surgical solution.

Robotics and laparoscopy have their own unique strengths in the surgical theatre, and we in pediatric urology at CHOP have proven that we can harness the advantages of both to the benefit of our patients. In fact, we do some of our major reconstruction like minimally invasive surgery (MIS), appendico-vesicostomy, and bladder augments as a hybrid approach utilizing the laparoscope for part of the procedure and the surgical robot for the other parts. We believe this decreases time and the cost of procedures that may lead to improved patient care.

Robotic surgery: Inception and growth

CHOP bought its first robot nearly 15 years ago, published some of the first robotic-assisted procedures in children, and trained some of the first pediatric fellows in robotic approach in children. Since then, we have a come a long way in broadening the scope of robotics in children.

Initial procedural choices for a robotic approach have been older children and very straightforward reconstructive goals like uncomplicated ureteropelvic junction obstruction (UPJO). We proved that this can be achieved quite successfully and have now utilized robot assistance for a variety of procedures, including redo pyeloplasty, pyeloplasty in complex kidney like horse-shoe kidney, ureteral reimplants and dismembered ureteral reimplants, retrovesical procedures, appendico-vesicostomies, and bladder augmentations.

The robotic approach offers some unique advantages that include surgical field magnification, hand-like instrumentation and three-dimensional vision. All of this enables one important game changing factor: It takes the surgeon to the organ and surgical field rather than deliver the organ to the skin surface as is dictum in open surgery. This enables reconstruction in its native position that allows excellent postoperative outcomes.

In the last few years, contributions from CHOP Urology to the field of minimally invasive surgery have changed surgical solutions in the following scenarios:

  • Uretero-ureterostomy as a primary surgical cure for duplex systems with reflux or obstruction
  • Enabling more salvage pyeloplasties that would have otherwise ended in nephrectomy
  • Enabling pyeloplasty in poorly functioning kidneys
  • Upper tract reconstruction in babies as young as 3 months of age 

Minimally invasive surgery for pediatric urological anomalies has arrived and is here to stay. As some of the leaders in pediatric urology, we believe it is our mission to embrace this change, improve it and harness its advantages to improve the lives of our patients, our children. 

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