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Single-port robotic surgery: First pediatric urology case series
Candace Granberg, M.D., Patricio C. Gargollo, M.D..
Mayo Clinic, Rochester, MN, USA.

Background: In the past two decades, technology has advanced to augment an already minimally-invasive approach in laparoscopic surgery. Robotic-assisted laparoscopic platforms have now evolved from a minimum of three working ports to its 4th-generation product: a single-port system, first cleared through the FDA for urologic procedures last year. A single, 2.5cm incision (Figure 1) allows for placement of a cannula (port) that admits a fully-wristed camera as well as three fully-wristed instruments, all controlled by the surgeon at the console. We sought to document the feasibility of the single-port (SP) robotic platform in the first clinical series of pediatric patients, reporting use of this system for dismembered pyeloplasty and Mitrofanoff. A secondary aim was to report intraoperative details and perioperative outcomes.
METHODS: Three patients, two girls (age 10 and 6 years) and one boy (age 23 months) diagnosed with ureteropelvic junction obstruction (UPJO) underwent SP robotic-assisted dismembered pyeloplasty using the da Vinci SP Surgical System (Intuitive Surgical, Sunnyvale, CA). Another child, (age 10y) underwent Mitrofanoff. A 2.5cm incision was made within the Pfannenstiel line in a HIdES fashion (Gargollo, J Urol, 2012) through which the 25-mm multichannel port was placed. The 12 x 10mm articulating robotic camera and two 6mm articulating robotic instruments were advanced. For the Mitrofanoff case, a 5mm assist port was placed for sutures.
RESULTS: All surgeries were completed successfully without any intraoperative complications or need for conversion. Median operative time for pyeloplasty was 120 minutes, inclusive of port placement, intraoperative antegrade stent placement and closure. All three patients were dismissed in less than 24 hours, taking only alternating acetaminophen and ibuprofen for pain control. The Mitrofanoff case was 240 minutes of console time, and with no complications intra- or post-operatively. There was no issue with instrumentation in the older patients; however, shorter working distance in the 23 month old pyeloplasty limited wristing of the instruments.
CONCLUSIONS: We report the first cases utilizing the SP robotic platform in children. Despite their smaller size and thus limited workspace for the articulating instruments, we had no issues with instrument clashing or triangulation in the older patients, completing dismembered pyeloplasty in a similar timeframe as with multiport robotic platforms. Use of the SP platform is not recommended if working distance will be <10cm from the end of the port as instrument movement is prohibitive. The HIdES approach of placing the port in the Pfannensteil line gave additional working distance from the UPJ, as well as keeping the incision below the swimsuit line for excellent cosmesis. Further study with additional cases will compare this approach with standard multiport robotic pyeloplasty to analyze and compare operative data and outcomes.


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