Abstract
Since the introduction of the Da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) in 1999, the market for robot assisted laparoscopic surgery has grown with urology. The initial surgical advantage seen in adults was for robotic prostatectomy, and over time this expanded to the pediatric population with robotic pyeloplasty. The introduction of three-dimensional visualization, tremor elimination, a 4th arm, and 7-degree range of motion allowed a significant operator advantage over laparoscopy, especially for anastomotic suturing. After starting with pyeloplasty, the use of robotic technology with pediatric urology has expanded to include ureteral reimplantation and even more complex reconstructive procedures, such as enterocystoplasty, appendicovesicostomy, and bladder neck reconstruction. However, limitations of the Da Vinci Surgical Systems still exist despite its continued technological advances over multiple generations in the past 20 years. Due to the smaller pediatric market, less focus appears to have been placed on the development of the smaller 5 mm instruments. As pediatric urology continues to utilize robotic technology for minimally invasive surgery, there is hope that additional pediatric-friendly instruments and components will be developed, either by Intuitive Surgical or one of the new robotic platforms in development that are working to address many of the shortcomings of current systems. These new robotic platforms include improved haptic feedback systems, flexible scopes, easier maneuverability, and even adaptive machine learning concepts to bring robotic assisted laparoscopic surgery to the next level. In this report, we review the present and upcoming technological advances of the current Da Vinci surgical systems as well as various new robotic platforms, each offering a unique set of technological advantages. As technology progresses, the understanding of and access to these new robotic platforms will help guide pediatric urologists into the next forefront of minimally invasive surgery.
Highlights
The introduction of laparoscopy for children with nonpalpable testicles in the 1960s has led to widespread adoption within the field of pediatric urology, and even replaced open surgery in some situations as the gold standard [1]
Adaptation of the robot into adult urology first occurred for prostatectomy [6], and pediatric urology soon followed with the first robotic pyeloplasty [7]
The robotic platform has been applied to other reconstructive procedures, including extravesical ureteral reimplantation [22], appendicovesicostomy [23], and even bladder augmentation [24]. It remains unclear if robotic ureteral reimplantation can provide superior, or even equivalent outcomes to the open correlate due to the high success rates of open surgery, but no significant differences in success rates or complication rates were seen in a recent multi-institutional study after the initial 30-case learning curve [22]
Summary
The introduction of laparoscopy for children with nonpalpable testicles in the 1960s has led to widespread adoption within the field of pediatric urology, and even replaced open surgery in some situations as the gold standard [1]. Laparoscopy enabled smaller surgical scars and decreased hospital stays, widespread use in complex reconstructive cases did not occur due to limitations on surgeon dexterity with available laparoscopic instruments, visualization, and sensory feedback [2, 3]. In pediatrics, the need for more delicate tissue handling and adaptation to a smaller operative working space posed a further challenge in minimally invasive surgery [4]. With progressing editions (S, Si, Xi, and X), Intuitive Surgical has advanced the system’s visualization and instrumentation, as well as its teaching capabilities with dualconsole systems and skill simulators
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