Pediatric Urologic Procedures Research Articles

Competence in pediatric urology upon graduation from residency: perceptions of residents, program directors and pediatric urologists

We aimed to clarify the scope of pediatric urological procedures that Canadian urology residents are perceived to be competent to perform upon graduation. We conducted a survey from April 2005 to June 2006 of urology residency program directors (UPDs), senior urology residents (SURs) and Pediatric Urologists of Canada (PUC) members from all 12 Canadian training programs. Questions focused on which of 23 pediatric urological procedures the 3 study groups perceived urology residents would be competent to perform upon completion of residency without further fellowship training. Procedures were based on the "A," "B" and "C" lists of procedures (least complex to most complex) as outlined in the Royal College of Physicians and Surgeons of Canada Objectives of Training in Urology. Response rates were 12/12 (100%), 41/53 (77%) and 17/23 (74%) for UPDs, SURs and PUC members, respectively. Average exposure to pediatric urology during residency was 5.4 (range 3-9) months and considered sufficient by 75% of UPDs and 69% of SURs, but only 41% of PUC members (p = 0.05). Overall, the 3 groups disagreed on the level of competence for performing level "A" and "B" procedures, with significant disagreement between PUC members and UPDs as well as SURs (p < 0.005). PUC members perceive Canadian urology residents' exposure to pediatric urology as insufficient and their competence for procedures of low to moderate complexity as inadequate. Further investigation regarding exposure to and competence in other emerging subspecialty spheres of urology may be warranted. Ongoing assessment of the objectives for training in pediatric urology is required.

Current controversies in pediatric urologic robotic surgery

Minimally invasive surgeries such as conventional laparoscopic surgery and robotic assisted laparoscopic surgery (RALS) have significant advantages over the traditional open surgical approach including lower pain medication requirements and decreased length of hospitalization. However, open surgery has demonstrated better success rates and shorter surgery time when compared to the other modalities. Currently, it is unclear which approach has better long-term clinical outcomes, greater benefits and less cost. There are limited studies in the literature comparing these three different surgical approaches. In this review, we will evaluate the advantages and disadvantages of RALS compared to conventional laparoscopic surgery and open surgery for commonly performed pediatric urological procedures such as pyeloplasty, ureteral reimplantation, complete and partial nephrectomy, bladder augmentation and creation of continent catheterizable channels. Although it is not yet possible to demonstrate the superiority of one single surgical modality over another, RALS has been shown to be feasible, well tolerated and advantageous in reconstructive urological procedures. With experience, the outcomes of RALS are improving, justifying its usage. However, cost remains a significant issue, limiting the accessibility of RALS, which in the future may improve with market competition and device innovation.

Parent and Patient Perceptions of Robotic vs Open Urological Surgery Scars in Children

Cumulative evidence shows that robot-assisted laparoscopic surgery is safe and at least as efficacious as open surgery for several pediatric urological procedures. Scars resulting from robotic surgery are often assumed to have a cosmetic advantage. However, no study has clearly demonstrated that parents and patients consistently prefer such scars. We developed 3 distinct surveys consisting of photographs and diagrams of scars resulting from open and robot-assisted laparoscopic surgery for ureteral reimplantation, pyeloplasty and bladder augmentation. Surveys were distributed to parents of patients being evaluated for 1 of the 3 procedures. The surveys evaluated information such as scar preference, reason for preference and demographics. Patients older than 7 years also completed surveys. Robot-assisted laparoscopic surgical scars were preferred by parents for all procedures studied (85% for ureteral reimplant, 63% for pyeloplasty and 93% for bladder augmentation). Patients also preferred the robotic scars (76%, 62% and 91%, respectively). Patients and parents did not differ significantly in scar preference or in rating of factors affecting decision. Scar size was important or very important to 80% of parents for reimplant, 83% for pyeloplasty and 86% for bladder augmentation. However, the majority of parents would ultimately base their choice of surgical approach on clinical efficacy rather than scar preference. Parents and patients prefer robot-assisted laparoscopic surgical scars to open surgical scars for pediatric ureteral reimplantation, pyeloplasty and bladder augmentation. Scar appearance is an important influence on the decisions of parents and patients, and should be discussed when surgical treatment is presented.

Contributing Factors for Cancellations of Outpatient Pediatric Urology Procedures: Single Center Experience

Surgery cancellations in the pediatric population are often due to preventable causes and can lead to decreased operating room efficiency. We hypothesized that clinical and demographic patient factors are associated with preventable cancellations of scheduled outpatient pediatric urology procedures at our institution. A retrospective review of cancelled outpatient pediatric urology procedures from January 1 to July 31, 2010 was performed. Data regarding demographics, procedure type, time to surgery from preoperative visit, reason for cancellation, potential operating room and surgeon lost revenue, and ultimate patient outcome were extracted from the electronic medical record. We identified 114 cancellations during the study period, comprising 13.3% of scheduled outpatient procedures. Preventable cancellations included insurance/financial related (11.4%), preoperative fasting violation (8.8%) and condition improved the day of surgery (4.4%). Nonpreventable cancellations included patient illness (40.3%), weather/traffic related (1.7%) and other nonspecified reasons (29%). Compared to nonpreventable cancellations, preventable cancellations were more likely associated with circumcision (OR 2.39, CI 1.04-5.46). Preventable cancellations were also associated with a shorter distance to the hospital (p = 0.03). There was no significant association between preventable cancellations and age, race/ethnicity, caregiver type or time to surgery. Potential associated lost revenue averaged $4,802 per cancellation. While the most common cause of surgical cancellation is patient illness, a significant number of cancellations are preventable. These findings suggest that future targeted hospital interventions, including improved evaluation of insurance status and preoperative parental education regarding preoperative requirements, may improve operating room use.

The adult urology perspective on management of stress urinary incontinence in pediatric urology: ICI‐RS 2011

The modern era of patient-centered, multidisciplinary professional practice comes with the expectation of effective interaction between specialties dealing with closely related clinical areas. Interaction between adult and pediatric urology is generally limited in terms of training, conferences, and joint diagnostic/treatment algorithms. However, in the more complex cases managed by pediatric urologists, long-term medical input is commonly necessary. Accordingly, regular interaction between the relevant specialties would be beneficial for continuity of care of individual patients, achieving best results at transition to adolescence, awareness of long-term outcome of pediatric urological procedures and development of new surgical techniques. This article reviews the discussions at the 2011 International Consultation on Incontinence Research Society meeting in Bristol.

Analysis of Octyl-2-Cyanoacrylate as a Dressing Material after Pediatric Urological Procedures

Analysis of Octyl-2-Cyanoacrylate as a Dressing Material after Pediatric Urological Procedures

Development of late, symptomatic abdominopelvic lymphoceles more than 10 years following pediatric reconstructive urologic procedures

Purpose Rare reports of symptomatic abdominopelvic lymphoceles following pediatric genitourinary reconstruction do exist; however there are no data regarding the development or management of late symptomatic lymphoceles. We report on the clinical presentation of these lymphoceles 10 or more years following initial urologic surgery. Materials and Methods We reviewed 480 patients following major intra-abdominal urologic reconstructive procedures from 1986 to 2009 for development of late, symptomatic abdominopelvic lymphoceles. A minimum of 10 years post-surgical follow up was required for inclusion. Results Late symptomatic lymphoceles developed in 4/480 (0.8%) patients. Median length of follow up post reconstruction was 13.5 years (range 10–17). Median time to lymphocele development was 12 years (range 8–16). Symptoms at presentation included abdominal distension (4/4, 100%), nausea and vomiting (3/4, 75%), flank pain/progressive hydroureteronephrosis (3/4, 75%), and obstructive pyelonephritis (1/4, 25%). Additional surgical procedures that may have contributed to lymphocele development were present in 100%. 75% (3/4) of the patients underwent open surgical drainage, with one electing observation for intermittent symptoms. Exploration revealed loculated fluid collections between bowel loops and dense adhesions; symptoms resolved although small asymptomatic recurrences developed in all patients. Conclusions Late, symptomatic abdominopelvic lymphoceles following major pediatric urinary tract reconstruction or diversion develop in <1% patients. Many undergo subsequent abdominopelvic surgery, which may contribute to development of these late, pathologic lymphoceles. Open surgical drainage is usually required with excellent outcome.

Meatotomy Using Local Anesthesia and Sedation or General Anesthesia With or Without Penile Block in Children: A Prospective Randomized Study

Meatotomy is a simple, common procedure for the treatment of meatal stenosis. We compared the outcomes of meatotomy performed using local anesthesia and sedation, and general anesthesia with and without penile block. A prospective comparative design was used. Participants included 76 boys 1.5 to 10 years old treated for meatal stenosis at a tertiary, university affiliated, pediatric medical center in 2008. Children were randomly allocated to undergo surgery with sedation and local anesthesia, or general anesthesia with or without penile block. All procedures were performed with the same method by the same surgeon. For local anesthesia EMLA 5% cream (lidocaine 2.5% and prilocaine 2.5%) covered with an occlusive dressing was applied 1 hour preoperatively, and midazolam (in patients younger than 5 years) or nitrous oxide (older than 5 years) was used for sedation. General anesthesia was induced with inhaled sevoflurane, and ropivacaine was used for dorsal penile nerve block. There was no difference among the groups in pain level intraoperatively (no pain in 92% to 93% of patients), 24 hours postoperatively (no pain in 81% to 88%) or after 1 month, or in complication rates (bleeding in 3 patients, laryngospasm in 2). General anesthesia with penile block was associated with a trend of less dysuria. Quality of void was excellent in 87% of patients at 24 hours and in 70% at 1 month, and parental satisfaction was high (88% to 92%). Meatotomy performed using local anesthesia and sedation has an equally good outcome to meatotomy performed using general anesthesia with or without penile block.

Avagard Hand Antisepsis vs. Traditional Scrub in 3600 Pediatric Urologic Procedures

Avagard is a waterless, scrubless, and brushless hand antiseptic approved by the Food and Drug Administration as a replacement for traditional presurgical brush hand scrubbing. We evaluated the use of Avagard compared with hand brush scrub preparation for inpatient and outpatient pediatric urological operations. We evaluated the first 1800 patients for whom we used Avagard as a preoperative hand antiseptic and compared them with the last 1800 consecutive patients for whom we performed traditional antiseptic-impregnated hand-brush scrubbing. All patients underwent a variety of inpatient and outpatient open, endoscopic, and laparoscopic pediatric urological procedures. Patients were monitored postoperatively for wound infection, and patients and surgeon were monitored for side effects. A cost analysis was performed. The incidence of wound infection was 2/1800 (0.11%) in the Avagard group and 3/1800 (0.17%) in the hand-scrub group (P > .99 Fisher's exact test). All wound infections were successfully treated with a single course of oral antibiotics. No side effects for the patients or surgeon were noted, including skin irritations or allergic reactions in either group. The traditional hand scrub is nearly 2 times more expensive per application than Avagard. The incidence of wound infections in pediatric urological procedures is low (0.09%). We observe that Avagard provides comparable hand antisepsis to the traditional surgical scrub in a variety of pediatric urological procedures. Avagard is superior to the surgical hand scrub in cost-effectiveness and time efficiency. Urologists should consider using Avagard for hand antisepsis before surgery.

Hernia After Pediatric Urological Laparoscopy

The incidence of port site hernia following adult laparoscopy is 0.1% to 3.0%. There are no known published reports concerning hernia incidence or related factors after pediatric urological laparoscopic interventions. We present our experience with port site incisional hernias following pediatric urological laparoscopy. We reviewed all pediatric urological laparoscopic procedures performed at Children's Medical Center Dallas from 2000 to 2008. A total of 261 cases were identified with followup available in 218 (83.5%). In 187 cases there were sufficient data to evaluate outcomes for each port site separately, and compare the size, location and fascial closure status to hernia development. Median patient age was 6.1 years (range 0.4 to 18.8). A total of 218 patients had a median followup of 5.7 months (range 0.2 to 83.4). Seven hernias (3.2%) were diagnosed at a median of 1.2 months (range 0.1 to 15.1) postoperatively. Patients with hernia were younger than those without hernia, at 1.1 years (range 0.5 to 3.9) vs 6.2 years (0.4 to 18.8, p = 0.04). We analyzed 571 port sites in 187 cases. In 385 ports (67.4%) the fascia was closed. Hernia developed in 4 of 385 ports (1.0%) that were closed and in 3 of 186 (1.6%) that were not closed. No significant relationship was observed between hernia development and port size or location. The incidence of port site hernia after pediatric urological laparoscopy was 3.2%, similar to the reported incidence in adults. While development of hernia after pediatric urological laparoscopy is rare, it is more likely to occur in infants. Due to the low incidence of this complication, it is difficult to draw conclusions regarding contributing factors.

14-Gauge Angiocatheter: The Assist Port

Minimally invasive techniques have emerged as the standard of care for some procedures in pediatric urology. In an effort to minimize required ports for robotic-assisted laparoscopic (RAL) surgeries in children, we describe in this article a novel technique for using a 14-gauge (G) angiocatheter as an assist port in concert with various readily available cystoscopic equipment. After the insertion of robotic ports and docking, the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA), using a 14-G angiocatheter, was placed through the abdominal wall under direct vision. The 14-G angiocatheter was then used to facilitate stent placement, provide a port for semiflexible cystoscopic graspers, and to evacuate cautery smoke. At the end of each case, the 14-G angiocatheter was removed under direct vision prior to undocking the robot. A 14-G angiocatheter was used as an assist port in 17 RAL urologic procedures (16 RAL dismembered pyeloplasties and 1 robotic orchiopexy). No complications occurred and the angiocatheter's use avoided the placement of 3- or 5-mm additional assist ports. The 14-G angiocath technique uses existing equipment, requires no closure, and can be placed anywhere on the abdominal wall. It allows the RAL dismembered pyeloplasty to be performed with only two instrument ports and no additional trocar for assistance. This is the first described method in the urologic literature of using a 14-G angiocatheter to maximize operative assistance while minimizing port placement in pediatric RAL surgery.

Behavior and Development in Children and Age at the Time of First Anesthetic Exposure

Several experimental studies have suggested that early exposure to anesthetic agents, i.e., before completion of synaptogenesis, can result in widespread apoptotic neuronal degeneration and late cognitive impairment, but human data are lacking. The authors performed a retrospective pilot study to test the feasibility and calculate sample sizes for a larger epidemiologic study of disturbed neurobehavioral development as a function of age at the time of first anesthetic exposure. Pediatric urological procedures were selected because the timing of surgery depends mainly on the age at which a diagnosis is made. Neurobehavioral development was assessed using the validated 120-item parental Child Behavior CheckList/4-18 in 314 children who were operated for pediatric urological procedures between the ages of 0 and 6 yr. Of 243 questionnaires returned, the total problem score was clinically deviant in 41 (23%) of children aged less than 24 months at the time of first surgery and 13 (20%) aged greater than 24 months. Crude and adjusted odds ratios for a clinically deviant Child Behavior CheckList/4-18 score increased with younger age at the time of surgery, but the confidence intervals were very wide. Adjusted odds ratio was 1.38 (0.59-3.22) when operated at age less than 6 months, 1.19 (0.45-3.18) when operated between 6 and 12 months of age, and 1.20 (0.45-3.20) when operated between 12 and 24 months (using operated at greater than 24 months of age as reference category). A properly powered cohort study would require at least 2,268 children. Children undergoing urologic surgery at age less than 24 months showed more behavioral disturbances than children in whom surgery was performed after age 2 yr, although the results were not statistically significant. To confirm or refute an effect of anesthesia on cognitive development, at least 2,268 children need to be studied. With retrospective study designs, residual confounding remains an issue that can only be solved in prospective randomized studies.

Robotic pediatric urology

Robotic-assisted minimally invasive surgery is penetrating pediatric urology. The freedom afforded by the "surgical actuators" has led to the expanding adoption of robotics, and it is unlikely that much of laparoscopy will not trend toward some iteration of robotic influence. The da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA) provides delicate telemanipulation, coalesced with three-dimensional visualization and superior magnification. It has bridged the gap between laparoscopy and open surgery. Nonetheless, a confident understanding of pure laparoscopy is paramount in the event that mechanical malfunction is experienced. Robotic pediatric urologic procedures such as pyeloplasty, ureteral reimplantation, abdominal testis surgery, and partial or total nephrectomy with or without ureteral stump removal are routinely performed at select centers offering robotic expertise. Complex reconstructive surgeries such as appendicovesicostomy, antegrade continent enema creation, and augmentation cystoplasty can be performed but are still in their infancy.

Short Stay Pyeloplasty: Variables Affecting Pain and Length of Stay

Pyeloplasty is increasingly performed on a short stay basis. We sought to determine what patient and treatment variables affect postoperative pain and length of stay, and whether an open approach could be considered "minimally invasive." We performed a retrospective review of patients younger than 10 years who underwent open pyeloplasty between 2001 and 2007. All patients received ketorolac every 6 hours and acetaminophen with codeine as needed. Data extracted from the medical records included morphine and codeine usage, patient age and gender, incision type, operative time, stent usage and outcome data (pain scores and length of stay). Multiple regression analyses were used to determine the association between variables and outcomes. A total of 51 patients met the inclusion criteria. Patient age and gender, operative time and stent usage had no significant correlation with mean or median pain scores. Children who received morphine had significantly higher mean, median and maximum pain scores and length of stay (33 vs 23 hours) than those who did not receive morphine. Multiple regression analyses revealed that morphine usage and dorsal lumbotomy incision were independently associated with higher mean, median and maximum pain scores, and a nephroureteral catheter was correlated with a higher maximum pain score. The only variable associated with length of stay was morphine usage. Morphine usage was the most significant variable associated with increased pain scores and increased length of stay. Ketorolac and acetaminophen/codeine provide better pain control, and allow children to return home within 24 hours. With mean pain scores less than 1 this series demonstrates that open pyeloplasty can be "minimally invasive."

Robot-Assisted Urologic Surgery: Safety and Feasibility in the Pediatric Population

To assess the safety and feasibility of performing robot-assisted pediatric urologic surgery with the da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, Calif) based on our experience with a variety of procedures. A retrospective review was performed of 53 robot-assisted pediatric procedures performed in our practice between September 2003 and March 2006. The procedures included 11 renal extirpative surgeries, 10 orchiopexies, 26 dismembered pyeloplasties, 2 uretero-ureterostomies, and 3 bladder surgeries. The mean patient age was 7.7 years, and the mean patient weight was 32 kg. All procedures were performed transperitoneally. All procedures were successfully completed with no conversions to open surgery. There was one procedure in which the robotic system malfunctioned, resulting in an unrecoverable loss of three-dimensional visualization and temporary loss of color. The only postoperative complication involved delayed return of bowel function that led to a diagnostic laparotomy with negative findings. A decrease in mean postoperative stay was noted in patients who underwent robot-assisted procedures compared with previous patients who had undergone open surgery. Robot-assisted surgery appears to be safe and feasible for a variety of pediatric urologic procedures. Prospective randomized studies are required to further evaluate the outcomes compared with open surgical procedures. Our initial experience has been encouraging and will serve as a foundation for future and more complex minimally invasive pediatric urologic operations.

Use of Avagard in pediatric urologic procedures

Objectives To evaluate the use of Avagard compared with a hand-brush scrub preparation by the urologist in preparation for inpatient and outpatient pediatric urologic operations. Avagard (chlorhexidine gluconate 1% solution and ethyl alcohol 61% wt/wt) is a waterless, brushless, and scrubless hand antiseptic indicated as a replacement for traditional preoperative brush hand scrubbing. Methods We evaluated the first 550 patients for whom we used Avagard as a preoperative hand antiseptic and compared them with the last 550 consecutive patients for whom we performed traditional antiseptic-impregnated hand-brush scrubbing. All patients underwent pediatric urologic procedures. Patients were monitored postoperatively for signs of wound infection, and patients and the surgeon were monitored for side effects. A cost analysis was performed to compare the use of Avagard as a preoperative hand preparation with that of an antiseptic-impregnated hand-brush. Results The incidence of wound infection was one in the Avagard group and two in the hand-scrub group, not a statistically significant difference. All wound infections were successfully treated with a single course of oral antibiotics without any long-term sequelae. No side effects for the patients or surgeon were noted, including skin irritations or allergic reactions in either group. The use of Avagard was more time efficient and cost effective. Conclusions To our knowledge, this is the first study demonstrating that Avagard is a fast, effective, easy to apply, and safe surgical hand preparation for pediatric urologic surgery. Its use is cost effective, as well as time efficient, in relation to the traditional surgical scrub.

OCTYL-2-CYANOACRYLATE AS A ROUTINE DRESSING AFTER OPEN PEDIATRIC UROLOGICAL PROCEDURES

Octyl-2-cyanoacrylate Dermabond, Ethicon, Inc., Sommerville, New Jersey is a synthetic tissue adhesive that has recently been used for skin closure in the treatment of minor lacerations. We assess its effectiveness as a sole dressing after open pediatric urological procedures. Between February and August 2003 we prospectively evaluated patients undergoing extragenital open and laparoscopic pediatric urological procedures at our institution. All open incisions were closed in layers using a final layer of self-absorbing subcuticular stitches for the skin before applying Dermabond only at the skin level. In laparoscopic cases Dermabond alone was applied to port sites (3 mm or less) and instrument sites without any sutures beneath the skin. No adjuvant occlusive dressings were applied to any of these wounds. All patients were allowed to bathe and return to activity immediately postoperatively. During the study period 146 patients with 200 incisions were identified (open 146, laparoscopy 54). Of these children 103 (142 incisions) returned for followup during the period of study with only 1 complication identified. This 6-month-old child presented the evening of surgery with omental prolapse through the umbilical port (3 mm port) requiring urgent closure. In no case was there an appreciable healing problem on surgeon or parental examination and no wound infections occurred. Dermabond alone provides a simple coverage for a myriad of pediatric urological surgical wounds. Early bathing and return to activity do not appear to impact negatively on wound healing when a simple skin barrier is used in place of standard dressings.

Pediatric surgical procedures

In this issue of the Atlas of the Urologic Clinics, the contributors discuss common surgical procedures and newer techniques in pediatric urology. Although these procedures are fundamental to the care of the pediatric urologic patient, each article in this issue provides readers with the individual author's nuances that he or she finds improves success rates. Common pediatric urologic procedures remain a significant part of the practice of most general urologists and although there is a significant degree of subspecialization inherent to pediatric urology, the expectation is that the general urologist will continue to perform more common procedures in children.

Pneumothorax in Pediatric Patients After Urological Laparoscopic Surgery: Experience With 4 Patients

Pneumothorax is a rare but known complication of adult urological laparoscopic surgery and has been described occasionally in children as well. The etiologies for pneumothorax during such procedures are discussed as is the management of pneumothorax in this setting. We investigate the occurrence of pneumothorax during laparoscopic pediatric urological procedures in children. Pneumothorax developed during urological laparoscopic procedures in 4 pediatric patients (3 females, 1 male). Patient age ranged from 8 months to 11 years (mean 5.4 years). Laparoscopic surgical procedures performed included right upper pole partial nephrectomy, left upper pole partial nephroureterectomy, removal of left multicystic dysplastic kidney and bilateral Cohen reimplantation of ureters. Procedures were performed with a maximum insufflation pressure of 15 mm Hg. During the same time period as these four cases, a total of 285 laparoscopic urologic procedures were performed at our institution. Pneumothorax was suspected due to decreased oxygen saturations, subcutaneous emphysema, increased respiratory effort and decreased chest lung sounds unilaterally. Pneumothorax was confirmed with chest x-rays. Operative time ranged from 171 to 249 minutes (mean 199.5). Duration of surgery before pneumothorax developed ranged from 75 to 239 minutes (mean 176, median 168). Conservative management of pneumothorax was used in 3 patients and a pigtail chest tube was used in 1. In all cases the estimated blood loss was minimal. Urologists performing laparoscopy in children should be aware of the possibility of a pneumothorax developing during the procedure. Evaluation for decrease in O2 saturation should include a search for pneumothorax in these patients. Close observation generally suffices for management.

Robotic Assisted Surgery in Pediatric Urology

Robotic assistance may permit more generalized development of laparoscopic reconstruction in pediatric urological procedures such as pyeloplasty and anti-reflux surgery. The relatively slow adaptation of laparoscopic techniques in reconstructive pediatric urology appears to be due to the challenges of efficient and accurate laparoscopic suturing. This review summarizes the current robotic options available for pediatric urological applications, the means of utilization, and early experience. The most commonly available robotic system is the daVinci® (Intuitive Surgical, Mountain View, California) with its EndoWrist technology that permits highly accurate and precise manipulation for laparoscopic dissection, tissue handling,and suturing. The system is large and costly in its current version, but has demonstrated its efficiency and potential in a wide variety of adult applications and now with pediatric uses. Most procedures performed have been transperitoneal, due to the large size of the instruments (12-mm camera port and two 8-mm working ports) and have included pyeloplasty, pyelolithotomy, extravesical anti-reflux procedures, and continent catheterizable stoma using appendix (Mitrofanoff). These procedures have largely been identical to those performed using conventional laparoscopy, and newer procedures will need to develop unique algorithms to take full advantage of the robotic system. Potential applications are numerous and this development is likely to contribute significantly to minimally invasive pediatric urology.