Case Studies: The Latest Robotic Surgery Advances in Pediatric Urology
Recent advances in robotic surgical systems are making minimally invasive procedures easier and more efficient than ever, even for the youngest, most complex patients. In May 2022, Children’s Health℠ acquired the da Vinci Xi, the most advanced iteration of the da Vinci surgical system. The team is using the da Vinci Xi to find new ways to apply robotics to complex procedures as well as everyday procedures for common conditions.
Craig Peters, M.D., Pediatric Urologist at Children’s Health and Professor at UT Southwestern, and his colleague, Yvonne Chan, M.D., Pediatric Urologist at Children’s Health and Assistant Professor at UT Southwestern, are eager to share two complex case studies of surgeries on infants with the da Vinci Xi, including an operation on both kidneys and a Y-V plasty to treat complex horseshoe kidney.
“The da Vinci Xi is highly versatile with enhanced capabilities that are enabling better outcomes, reducing operating time and expanding what’s possible with robotics,” Dr. Peters says.
Case Study #1: Efficiently Operating on Both Kidneys of a 6-Month-Old
A 6-month-old baby had a duplicated left kidney with an ectopic ureter. The left kidney had reasonable function, but because urine wasn’t draining freely, she had hydronephrosis and needed surgery to prevent further damage. On the right kidney, she also had severe vesicoureteral reflux and recurrent infections that increased her risk of kidney damage.
Dr. Peters and the team opted to operate on both kidneys during the same procedure.
“This procedure required us to work in three quadrants of the abdomen, which was not easy to do in older robotic systems,” Dr. Peters explains. “With the da Vinci Xi, we could pivot the boom to operate in different quadrants, rather than having to undock the system and reposition the room based on which quadrant we were operating in. This is much easier, more efficient, and I believe that translates to an even safer procedure.”
Dr. Peters began the procedure on the left side with a ureteroureterostomy.
“With the total visualization we have with da Vinci Xi, we could make the anastomosis of the upper portion to the lower portion and remove the extra ureter all the way down to the bladder with three 8.5 millimeter incisions,” Dr. Peters says.
After operating in the top left quadrant near the kidney, Dr. Peters pivoted the robotic system to the bottom right quadrant to begin the ureteral reimplant, the treatment for vesicoureteral reflux.
The team completed the procedure in 4.5 hours, and the patient was discharged the next day.
“I estimate we had a 20% reduction in operating time compared to older robotic systems, and I expect this will be reduced even further as our team has more experience with the da Vinci Xi,” Dr. Peters says. “This means less anesthetic for the patient and overall better outcomes.”
Case Study #2: Y-V Plasty on an Infant with Complex Horseshoe Kidney
A 9-month-old had a horseshoe kidney with the ureteropelvic junction obstruction with high ureteral insertion. This caused poor drainage and severe bilateral hydronephrosis.
Instead of a typical pyeloplasty approach, the team determined that a Y-V plasty was the best treatment for this patient. During a Y-V plasty, the ureter isn’t completely disconnected from the kidney. Instead, the urologist cuts along the edge of the ureter and a side of the renal pelvis in order to make the new ureteropelvic junction at a lower point, enabling better drainage.
“The Y-V plasty is very useful in cases where the ureter insertion is high and there is a big renal pelvis, which was the case for this patient,” Dr. Chan says. “We decided on a staged approach, beginning with the first Y-V plasty on the right kidney.”
In this procedure, Dr. Chan leveraged the da Vinci Xi’s targeting feature, which uses the camera to target the patient’s anatomy so the system will automatically adjust the boom and robotic arms to maximize operating space.
“This area is difficult to access, and the procedure requires precision within the tiny real estate of this small baby’s abdomen,” Dr. Chan explains. “The targeting feature not only enabled more efficient setup and docking, but it also minimized the risk of clashing the robotic arms, which tends to occur more in older robotic systems. The da Vinci Xi system, as well as Dr. Peters’ guidance, enabled us to safely and efficiently perform this Y-V plasty.”
Dr. Chan completed the procedure in about four hours. The patient was discharged home the next day, and the second procedure for the left kidney will take place within a few months of this first procedure.
Why Children’s Health Urology: Ensuring Robotic Surgery Excellence
The Children’s Health Pediatric Urology Program performs some of the highest volumes of robotic surgeries in the U.S., and all of the physicians are certified in the da Vinci system. Fellows and residents also join for every procedure to observe and participate through a dual console on the da Vinci Xi.
“As we explore even more complex procedures with the da Vinci Xi, safety and excellence continue to be our top priority,” Dr. Chan says. “That’s why we’ve spearheaded a safety simulation training program for urologic robotic surgery in the U.S. Although complications are rare, we prepare every team member – from fellows to urologists to nurses to anesthesiologists – for an emergency situation so we can safely perform the most advanced robotic procedures.”
You can also learn more about the world-class pediatric urology fellowship program at UT Southwestern and Children's Medical Center Dallas. About the fellowship program >>
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