Robotic Partial Nephrectomy in the Pediatric Population

Dr Priyank Yadav, SGPGI, Lucknow

Since the first reported case of Robotic partial nephrectomy (RPN) in a pediatric patient in 2012, this technique has expanded in its application for various benign and malignant renal masses in children.(1) Just over 30 cases of pediatric RPN have been reported in the literature till now. Compared to open partial nephrectomy, robotic approach demonstrates reduced blood loss, shorter hospital stay, and similar renal functional outcomes.

The initial RPN case involved a 14-year-old diagnosed with clear cell RCC.(1) Subsequent reports have expanded RPN applications to include Wilms’ tumors, nephrogenic rests, RCC, cystic nephroma, and angiomyolipoma. Careful patient selection through high-quality cross-sectional imaging can delineate the relationship of the tumor to the vascular and collecting system, aiding in RPN planning. Three-dimensional reconstructions enhance the topographical details from standard CT and MRI.(2)

While mimicking port placements from the adult RPN literature, pediatric cases necessitate modifications for smaller patients. All ports placed in the midline can optimize distance between the trocars.(1) Both transperitoneal and retroperitoneal approaches have been documented for pediatric RPNs.(3,4) Mean operative times ranged from 110 minutes for a cystic nephroma resection to 293 minutes for segmental nephrectomies.(5,6 Ischemia times during tumor resection are minimized through selective arterial clamping facilitated by preoperative planning. Median ischemia times in the literature vary from 14 min to 31 min.(4,7) Novel adjuncts like near infrared and fluorescent imaging using indocyanine green (ICG) can further reduce global renal ischemia.(2)

RPN in children is associated with reduced intraoperative blood loss, analgesia requirements and length of stay.(8) While there is a lack of studies directly comparing margin status between robotic and open approaches in the pediatric population, adult studies have indicated comparable results in terms of positive surgical margins.(9) Nonetheless, additional research is needed to explore this aspect further.

Enhancing procedural standardization is feasible through shared knowledge between pediatric and adult urologists with extensive minimally invasive surgery experience. However, literature on formalized partnerships for robotic partial nephrectomies is limited.(6,7,10) Antar et al. (2022) explored a cooperative model, where adult urologists managed technical aspects, and pediatric specialists provided patient-tailored guidance.(10) Despite its feasibility in a single-center analysis with 6 patients, long-term follow-up on metrics like renal function preservation is lacking. Widespread adoption of such collaborations could advance training in cutting-edge robotic surgery for the next generation of pediatric urologists.