Current practices in robotic surgery for distal ureter in children: results from an EAU robotic urology section (ERUS) survey

Introduction: The robotic approach for uretero-vesical junction (UVJ) anomalies in children is still limited and debated. Both paediatric and adult urologists perform these procedures. This survey-based descriptive study aimed to evaluate different robotic approaches to the UVJ anomalies and their spread among ERUS Urologists performing robotic surgery in children, focusing on indications, technical aspects and outcomes.

Materials and methods: A survey was distributed to ERUS members to gather data on paediatric patients treated for UVJ anomalies between January 2017 and December 2022. Data were collected on demographics, diagnoses, surgical details, complications, and postoperative outcomes.

Results: Three Centres participated in the survey. A total of 153 patients were included in the study. Centre 1 participated with a series of 6 patients: (4 D-RALUR, ND-RALUR). Centre 2 participated with a series of 67 patients (2 D-RALUR, 65 ND-RALUR). Centre 3 participated with a series of 80 patients (56 D-RALUR, 16 ND-RALUR and 7 UU). The surgery success rate varied from 50% to 100%. No life-threatening events were reported. The main complications were the need for further surgery due to persistent VUR or post-operative UVJ obstruction.

Conclusions: Robotic approach to the distal ureter in children is still not widely performed by ERUS Urologists. The most performed procedure is ND-RALUR. Robotic-assisted distal ureter surgery seems to be safe and feasible in paediatric patients, but further studies and experience are needed. This survey provides a general overview of the robotic-assisted surgical approach to distal ureter disease in the paediatric population and its different popularity and outcomes.

1 Introduction

Interest in pediatric robotic surgery has grown in recent years. Urology seems to be particularly benefiting from this technology, as seen in adult cases (1). Indeed, robotic technology improves surgeons' vision, movements and precision (2) especially in limited anatomical spaces.

Improved safety and efficacy in pediatric cases have been reported, promoting surgeons to expand indications for robot-assisted procedures (3–5). While surgery for ureteropelvic junction (UPJ) in adults has been widely performed for years and supported by scientific evidence (6, 7), the approach to the ureterovesical junction (UVJ) and distal ureter in pediatric patients remains less common and less standardized.

Pediatric UVJ pathologies include vesicoureteral reflux (VUR), primary obstructive megaureter (POM), refluxing-obstructive megaureter (ROM) and secondary megaureter (sec MU). Several surgical techniques have been reported. The most popular procedure is the open cross trigonal reimplantation by Cohen, which has favourable outcomes but is associated with important limitations. Minimally invasive procedures are still less common but seem to have some advantages and the EAU guidelines do not yet recommend these approaches as a routine technique (6). Robot-assisted laparoscopic ureteral reimplantation (RALUR) is suggested in patients with complex anatomy and/or after failed injective treatment or open ureter reimplantation.

The aim of this survey is to evaluate different robotic approaches for UVJ anomalies among ERUS urologists who perform pediatric robotic surgery, focusing on indications, technique variations, short and long-term outcomes.

2 Materials and methods

Between December 2022 and March 2023, ERUS members were invited by the leading Centre to participate in this survey. Respondents were asked to complete a questionnaire on pediatric patients treated between January 2017 and December 2022 for UVJ anomalies with intravesical robotic vesicoureteral reimplantation, extravesical robotic dismembered reimplantation (D-RALUR), extravesical robotic non-dismembered reimplantation (ND-RALUR) and uretero-ureterostomy (UU). Patients up to 18 years of age, who underwent robotic-assisted surgical treatment for VUR, POM, ROM, or sec MU and who had not received previous treatment or had not responded to conservative, endoscopic, or surgical interventions were included. Patients were excluded if they were over 18 years old, had a follow-up period of less than six months, or had a neurological bladder.

The questionnaire was structured in three sections, as shown in Appendix 1. The first section contained demographic data on patients and clinical indications for the procedure performed. The second section concerned surgical details of the procedure. Finally, the last section was dedicated to information about follow-up and outcomes.

The data to be entered and the questions for the centres were devised by the paediatric urology team at the leading centre based on the main points of interest in the literature on this subject.

Demographics, diagnosis, surgical details, complications and post-operative outcomes were recorded by participating centres and collected by the leading centre. Collected data were analysed with descriptive statistics.

As regards the definition of surgical success, clinical success was defined as resolution of symptoms, while radiological success was defined as evidence from instrumental examinations of resolution of the obstructive or reflux condition.

2.1 Surgical techniques

The robotic techniques assessed included D-RALUR, ND-RALUR, and UU. We collected details of patient positioning, port placement, ureteral isolation, and reimplantation approaches as applied by the surgeons at each participating centre. Specific surgical steps varied slightly among centres based on procedural preferences and institutional protocols.

D-RALUR: chosen in patients with UVJ primary or secondary obstruction and with ROM.

Patient supine, 15–20° Trendelenburg position. A bladder catheter is placed. The 8 mm 0° camera port is placed at the umbilical site. Two or three 8 mm ports are placed on the transverse umbilical line, with a minimal distance of 4 cm between ports. The ureter is identified at or below its crossing point with the iliac vessels and mobilized. The UVJ is exposed and isolated, preserving its vascular peduncles, vas deferens and uterine artery. Detrusotomy is then performed without mucosa layer opening. The distal part of the ureter is resected at the UVJ. If not placed before the procedure, the ureteral stent is inserted. If required, ureteral remodelling is performed according to the surgeon's preferences. The anastomosis is completed and the detrusor is sutured, wrapping the ureter. In case of tense anastomosis, the bladder dome could be mobilized to better reach the ureter or a psoas hitch can be performed.

ND-RALUR: usually performed in patients with VUR without signs of obstruction. Patient positioning, trocar placement and ureteral isolation and dissection are similar to D-RALUR. The ureter is not resected but directly reimplanted over the bladder mucosal layer, according to the Lich-Gregoir technique.

UU: considered for patients affected by a duplex collecting system with obstruction or ectopy of the upper moiety ureter or a single system with ureteral stricture and short ureters, usually secondary to previous surgeries at the UVJ; it can be performed by ipsilateral or contralateral anastomosis.

In cases of duplex systems, an ipsilateral UU is performed. The orthotopic non-refluxing ureter is stented by preoperative cystoscopy. Trocars placement is the same as for RALUR. The ureters are identified below their crossing with the iliac vessels. The pathological one is then mobilised, ligated, and resected as distally as possible. An ureterotomy of approximately 1 cm in length is performed on the orthotopic ureter and an end-to-side anastomosis is completed.

In cases of single systems with long-standing obstruction and/or ischemia of the distal ureter, especially in those patients who have previously undergone surgical treatments that may result in insufficient ureter length, a crossed UU could be performed. In this case, as well, a cystoscopy is performed prior to the robotic procedures to stent the healthy ureter on the contralateral side. The ureter to be reimplanted is isolated and dissected as distally as possible and the pathological distal tract is removed. The contralateral ureter can be reached through a retrocolic window. Indocyanine green fluorescence (ICG) could be used to check the ureteral blood supply. Ureterotomy is performed on the contralateral ureter and the end-to-side anastomosis is completed.

3 Results

Three Centres participated in the survey: IRCCS G. Gaslini, Genoa (Italy), AOU Careggi, Florence (Italy) and Memorial Hospital Group, Istanbul (Turkey).

A total of 153 patients were included (6 Florence, 67 Istanbul, 80 Genoa).

Surgical procedures performed were ND-RALUR in 84 patients, D-RALUR in 62 and UU in 7. Main results are summarised in Tables 1–3.

Table 1

Table 1. Summary of ERUS survey results—part 1.

Table 2

Table 2. Summary of ERUS survey results—part 2.

Table 3

Table 3. Summary of ERUS survey results—part 3.

Among D-RALUR, mean operative time range was between 155 and 219 min, while in ND-RALUR was between 122 and 124 min. The most reported ureteral remodelling technique reported was the one according to Hendren. All centres reported using different methodologies for planning the submucosal tunnel for ureterovesical reimplantation. The indication for ND RALUR was the same for all centres, i.e., vesicoureteral reflux, while for D-RALUR the indications were more varied and less uniform between the enrolled Centres.

All the Centres reported the clinical success for each procedure. Only one Centre recorded both clinical and radiological success.

Complications classified as IIIb according to Clavien Dindo classification (7) were collected specifically. Need for endoscopic treatment after surgery were considered as grade IIIb as well, due to need for general anesthesia. The main results concerning D-RALUR and ND-RALUR are summarised in Table 4.

Table 4

Table 4. Summary of ERUS survey overall results—All centres combined.

No intraoperative complications and no conversion to open procedure were reported by the centres.

Centre 1 (Florence) used DaVinci Si in ND-RALURs and DaVinci Xi in D-RALURs. Centre 2 (Istanbul) and Centre 3 (Genoa) used DaVinci Xi.

4 Discussion

In recent years, the adoption of robot-assisted surgery in pediatric settings has increased, especially in urology (4, 8). Cohen's open reimplantation remains the most performed operation with excellent results reported in the literature (9, 10). As new minimally invasive surgical techniques have become available, numerous authors have analyzed and compared the different approaches in terms of feasibility, cost, safety, and outcomes (11–14).

An important issue in the patient undergoing Cohen's reimplantation is the frequent difficulty in performing endoscopic maneuvers such as stent placement or ureterorenoscopy (15, 16). Other issues are pain, bladder spasm, length of stay, need for drain tubes, and risk of vas deferens injuries. All of them seem to be improved by a robotic approach (13, 17–25). Better visualization can reduce the risk of pelvic plexus and vas deferens damage (26). Urinary retention is reported as a common complication after ureteral reimplantation (27), with a frequency up to 10%, especially in bilateral cases (28, 29), but seems to be less frequent in robotic surgery compared to open procedures (27). This complication was not reported in our survey. Open procedures are thought to carry a higher risk of voiding dysfunction because of the cystotomy or because of neuropraxia from dissection (26, 30).

ND-RALUR seems to be safe and effective even in patients with previous surgical treatment and complex anatomy (31). Literature on D-RALUR remains sparse, although preliminary data and the experiences of our centres seem encouraging.

VUR is the most common indication for pediatric reimplantation. Less frequent indications are POM, sec MU, ROM, ureterocele and ectopic ureters. Even if RALUR is still not considered the gold standard procedure, it can be a valid choice in patients with complex anatomy and/or after failed treatments, as reported by EAU 2024 guidelines (6, 32).

We found a variation in procedural preferences, between ND and D-RALUR. Overall, ND-RALUR was the most performed procedure, but the prevalence varies depending on the Institution. In the two series with the higher number of cases, one centre performed almost exclusively ND-RALUR, while the other one performed both procedures with a higher number of D-RALUR. This is related to the different surgical indications depending on the underlying pathology, thus in patients' selection. Regarding Centre 2, we do not know if the lower number of D-RALUR compared to ND-RALUR is due to a lack of indications or a preference for a different surgical approach, such as open surgery, for more complex cases.

As regards the detrusor tunnelling, some authors use the diameter of the distal ureter as a parameter, with different ratios reported (28, 33, 34). Other authors use a specific length (35). Results from this survey are similarly not uniform: Centre 3 reported a mean length of 4 cm in ND-RALUR procedure and 4.1 cm in D-RALUR, while Centre 1 used the 3:1 rule. Centre 2 reported no details on this topic.

In bilateral UVJ pathology, it is important to consider whether to perform the correction in one or two stages. Some Authors reported higher risk of post-operative urinary retention and complications in bilateral procedure (36, 37). Recently Hajiyev showed that bilateral RALUR seems to be safe and not related to a higher risk of complications (38). In this ERUS survey, there was no evidence of differences in outcomes among bilateral procedures, and no cases of acute postoperative urinary retention were reported. The 3D visualization provided by robotic technology allows visualization of the neurovascular bundle and avoidance of intraoperative damage, as suggested by other Authors (38).

All three Centers usually removed the urinary catheter on the first postoperative day, similar to the literature (26, 27, 39). Longer catheterization was typically due to a suspected urinary leak. Interestingly, some Authors report no need for post-operative catheter after ND-RALUR in unilateral primary VUR (40). On the other hand, some Centres keep the catheter for a longer time after dismembered procedures (41).

In patients with severe ureter distension, a distal remodelling is frequently chosen. The most popular techniques are tapering by Hendren (42) and tailoring by Kalichinski (43) or Starr (44). This could provide a better urine flow (45) and prevent VUR, although with no strong scientific basis for effectiveness (46, 47). In our survey, the Hendren type was the most frequently performed by all Centres.

An intraluminal stent is generally used in case of D-RALUR to protect the anastomosis and prevent leak or transient obstruction (27, 48). Even if stentless pyeloplasty has been described (49–51), there is no evidence about stentless robotic ureteral reimplantation in terms of safety and efficacy. In ND procedures, stenting is usually not performed (14). This survey showed conformity between Centers 1 and 3, which did not use the stent in the ND-RALUR; Centre 2 placed the stent before performing ND-RALUR only in patients with abnormal anatomy, such as a duplex system or solitary kidney. In D-RALUR procedures, all Centers placed the stent during the robotic procedure. Some Authors prefer to place it with a preliminary cystoscopy (32).

The timing of stent removal in our D-RALUR groups seems to be slightly longer than that suggested by other Authors (41, 52), which is usually between 2 and 8 weeks. Nevertheless, there is no consensus. Interestingly, some studies about ureteric surgery showed that an early removal might be safe without increasing the risk of urinary leak (53–55).

Literature about robotic outcomes is still discordant (29, 56). RALUR outcomes are quite variable, with a surgical success rate between 77% and 100% (28). In ND-RALUR, persistent VUR rate is 23% (29). The overall complication rate for ND-RALUR is variable among the Authors' reports, with a wide range (0%–14%) (26, 57–59). One of the most important complications is ureteral obstruction, usually due to transient oedema, thus suggesting that stent placement is mandatory in case of a solitary kidney or persisting obstruction (27). The need for postoperative stenting ranges between 0% and 10% (25, 60, 61). In this survey, 5 cases treated by ND-RALUR required a post-operative ureteral stenting due to UVJ obstruction, describing a post-operative obstruction rate of 29.4%. Stenting was effective in solving the obstruction.

After D-RALUR, anastomotic leak and stenosis are the most concerning complications. Centre 3 reported 4 patients with post-operative UVJ obstruction (7.1%) treated by endoscopic stenting. After an open procedure, 6.6% of patients experience post-operative obstruction (62). Literature on obstruction after dismembered reimplantation is still poor; Mittal reported no leak or stenosis after D-RALUR for POM, finding a general low complication rate, comparable to ND-RALUR (41). Even regarding obstruction rates after D-RALUR, the results from this survey seem similar to those of other Authors' experiences (47, 52). A temporary postoperative hydronephrosis is not rare, and the resolution is usually spontaneous; this finding seems to be comparable with open and robotic reimplantation (63).

De-novo or persistent VUR is another major issue after ND procedures and it's usually defined by post-op VCUG, with variable grade and rate between Authors (29, 37). Regarding VUR after dismembered procedures, there are few data (64, 65). In general, surgical success for VUR treatment can be defined by symptoms resolution or radiologically defined as the absence or reduction of reflux. For this reason, there is often no uniformity in the literature (31). In this ERUS survey, Centre 1 and Centre 3 reported clinical success, while Centre 2 provided both clinical and radiological success. Regarding ND-RALUR group the reported success rate ranged between 50% and 100%. Centre 1 reported a 50% rate; Centre 2 reported a clinical success rate of 97% and a radiological one of 100%, but only 33% of the patients had undergone VCUG. Centre 3 reported a 71% success rate. In D-RALUR, success rates varied from 67% to 100% (67% from Centre 3, 50% from Centre 1 and 100% from Centre 2, but the last series only consists of 2 procedures).

Open techniques for VUR repair have well-known good outcomes (66, 67). Nevertheless, a recent meta-analysis suggests similar outcomes between ND-RALUR and open reimplantation in VUR patients (58), but further long-term studies are needed. RALUR complexity seems to be underestimated and its learning curve is long, which potentially may affect success rates analysis (61).

Ureteroureterostomy is mostly performed in children with mid-ureteral obstruction and minimally invasive techniques seem to be safe with good results, even compared to open surgery (68–71). The anastomosis can be ipsilateral or contralateral (trans-ureteroureterostom y72). In this survey, only Centre 3 performed UU and the main indication was duplex system. Similarly to data from literature, the reported success rate was 85.7% with a low complication rate (73). Only one patient among contralateral anastomosis group had post-operative obstruction, which was solved with temporary stenting. The mean operative time was similar or shorter than other series (73, 74), although the definition of procedure timing may be different depending on the Author. UU seems to be a safe and effective alternative to the same open procedure (68, 75, 76). Nevertheless, despite encouraging results, this procedure is not yet widely performed in pediatric patients.

The main limitations of our survey are the heterogeneous patient samples, the retrospective design of the study and the descriptive nature since it is a survey. Moreover, this survey did not focus on differences between surgeons' skill and experience, as it didn't analyse the respective learning curves.

5 Future perspectives

Given the increasing availability and uptake of robotic surgery in paediatrics, we believe that reconstructive ureteral procedures represent a suitable platform for further developing and refining these techniques. To strengthen the evidence base, more standardised and prospective studies will be required. Moreover, because paediatric surgery inherently involves smaller patient cohorts compared with adult practice, we consider multicentre and international collaboration essential to ensure adequate sample sizes and more generalisable findings.

6 Conclusions

This survey collected a substantial cohort of pediatric patients who underwent robotic surgery of the distal ureter. Our findings suggest that adult urologists do not frequently perform pediatric robotic procedures, which is becoming increasingly popular among pediatric urological specialists.

The main indication for RALUR among ERUS members is VUR, according to the literature.

RALUR has gained popularity, showing promising outcomes (41, 77). Although results are still not comparable to open techniques, urologists must keep on developing minimally invasive approaches, comparing results and discussing indications and procedures.

Further multicentric studies and surveys are needed to improve the development and the popularity of robotic procedures treating distal ureteral pathologies in children.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

Ethical approval was not required for the study involving humans in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was not required from the participants or the participants' legal guardians/next of kin in accordance with the national legislation and the institutional requirements.

Author contributions

GM: Conceptualization, Methodology, Supervision, Validation, Writing – review & editing, Funding acquisition. LG: Conceptualization, Data curation, Formal analysis, Investigation, Visualization, Writing – original draft. MC: Conceptualization, Data curation, Supervision, Validation, Writing – review & editing. AM: Conceptualization, Supervision, Writing – review & editing. FS: Data curation, Formal analysis, Investigation, Writing – review & editing. MS: Conceptualization, Methodology, Supervision, Validation, Writing – review & editing. HJ: Conceptualization, Supervision, Validation, Writing – review & editing. VF: Conceptualization, Data curation, Funding acquisition, Investigation, Project administration, Writing – original draft.

Funding

The author(s) declared that financial support was received for this work and/or its publication. This work was supported by the Italian Ministry of Health (5 per Mille Project).

Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The reviewer GL declared a past co-authorship with the author GM to the handling editor.

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References

1. George EI, Brand TC, LaPorta A, Marescaux J, Satava RM. Origins of robotic surgery: from skepticism to standard of care. JSLS J Soc Laparoendosc Surg. (2018) 22(4):e2018–00039. doi: 10.4293/JSLS.2018.00039

Crossref Full Text | Google Scholar

2. Spinoit AF, Nguyen H, Subramaniam R. Role of robotics in children: a brave new world!. Eur Urol Focus. (2017) 3(2–3):172–80. doi: 10.1016/j.euf.2017.08.011

PubMed Abstract | Crossref Full Text | Google Scholar

3. Passerotti C, Peters CA. Pediatric robotic-assisted laparoscopy: a description of the principle procedures. ScientificWorldJournal. (2006) 6:2581–8. doi: 10.1100/tsw.2006.399

PubMed Abstract | Crossref Full Text | Google Scholar

4. Mei H, Tang S. Robotic-assisted surgery in the pediatric surgeons’ world: current situation and future prospectives. Front Pediatr. (2023) 11(February):1–7. doi: 10.3389/fped.2023.1120831

Crossref Full Text | Google Scholar

5. Mahida JB, Cooper JN, Herz D, Diefenbach KA, Deans KJ, Minneci PC, et al. Utilization and costs associated with robotic surgery in children. J Surg Res. (2015) 199:169–76. doi: 10.1016/j.jss.2015.04.087

PubMed Abstract | Crossref Full Text | Google Scholar

6. EAU Guidelines. Edn. Presented at the EAU Annual Congress Madrid 2025. (2025). ISBN 978-94-92671-29-5.

Google Scholar

7. Dindo D, Demartines N, Clavien P. Classification of surgical complications. Ann Surg. (2004) 240(2):205–13. doi: 10.1097/01.sla.0000133083.54934.ae

PubMed Abstract | Crossref Full Text | Google Scholar

8. Boscarelli A, Giglione E, Caputo MR, Guida E, Iaquinto M, Scarpa M-G, et al. Robotic-assisted surgery in pediatrics: what is evidence-based?—a literature review. Transl Pediatr. (2023) 12(2):271–9. doi: 10.21037/tp-22-338

PubMed Abstract | Crossref Full Text | Google Scholar

9. Kennelly MJ, Bloom DA, Ritchey ML, Panzl AC. Outcome analysis of bilateral Cohen cross-trigonal ureteroneocystostomy. Urology. (1995) 46(3):393–5. doi: 10.1016/S0090-4295(99)80226-X

PubMed Abstract | Crossref Full Text | Google Scholar

10. Barrieras D, Lapointe S, Reddy PP, Williot P, McLorie GA, Bigli D, et al. Are postoperative studies justified after extravescial ureteral reimplantation? J Urol. (2000) 164(3 Pt 2):1064–6. doi: 10.1016/S0022-5347(05)67251-5

PubMed Abstract | Crossref Full Text | Google Scholar

11. Carlucci M, Fiorenza V, Wong MC, Damasio MB, Mattioli G. Minimal invasive surgery of the distal ureter : indications, advantages and technical considerations from a single-center preliminary experience. J Pediatr Endosc Surg. (2020) 2(1):1–9. doi: 10.1007/s42804-020-00047-9

Crossref Full Text | Google Scholar

12. Kruppa C, Wilke A, Hörz C, Kosk T, Hörz T, Fitze G, et al. Vesicoscopic vs. open ureteral reimplantation according to Cohen and leadbetter-politano for vesicoureteral reflux. J Clin Med. (2023) 12(17):5686. doi: 10.3390/jcm12175686

PubMed Abstract | Crossref Full Text | Google Scholar

13. Babu R, Chandrasekharam VVS. A systematic review and meta-analysis comparing outcomes of laparoscopic extravesical versus trans vesicoscopic ureteric reimplantation. J Pediatr Urol. (2020) 16(6):783–9. doi: 10.1016/j.jpurol.2020.09.006

PubMed Abstract | Crossref Full Text | Google Scholar

14. Esposito C, Escolino M, Lopez M, Farina A, Cerulo M, Savanelli A, et al. Surgical management of pediatric vesicoureteral reflux: a comparative study between endoscopic, laparoscopic, and open surgery. J Laparoendosc Adv Surg Tech. (2016) 26(7):574–80. doi: 10.1089/lap.2016.0055

PubMed Abstract | Crossref Full Text | Google Scholar

15. Adam A. A simple and novel method to attain retrograde ureteral access after previous Cohen cross-trigonal ureteral reimplantation. Curr Urol. (2017) 11(1):42–7. doi: 10.1159/000447193

PubMed Abstract | Crossref Full Text | Google Scholar

16. Krambeck AE, Gettman MT, BaniHani AH, Husmann DA, Kramer SA, Segura JW. Management of nephrolithiasis after Cohen cross-trigonal and glenn-anderson advancement ureteroneocystostomy. J Urol. (2007) 177(1):174–8. doi: 10.1016/j.juro.2006.08.112

PubMed Abstract | Crossref Full Text | Google Scholar

17. Stanasel I, Atala A, Hemal A. Robotic assisted ureteral reimplantation: current status. Curr Urol Rep. (2013) 14(1):32–6. doi: 10.1007/s11934-012-0298-1

PubMed Abstract | Crossref Full Text | Google Scholar

18. Barbosa JABA, Barayan G, Gridley CM, Sanchez DCJ, Passerotti CC, Houck CS, et al. Parent and patient perceptions of robotic vs open urological surgery scars in children. J Urol. (2013) 190(1):244–50. doi: 10.1016/j.juro.2012.12.060

PubMed Abstract | Crossref Full Text | Google Scholar

19. Leijte E, de Blaauw I, Van Workum F, Rosman C, Botden S. Robot assisted versus laparoscopic suturing learning curve in a simulated setting. Surg Endosc. (2020) 34(8):3679–89. doi: 10.1007/s00464-019-07263-2

PubMed Abstract | Crossref Full Text | Google Scholar

20. Sahadev R, Spencer K, Srinivasan AK, Long CJ, Shukla AR. The robot-assisted extravesical anti-reflux surgery: how we overcame the learning curve. Front Pediatr. (2019) 7(Mar):1–8. doi: 10.3389/fped.2019.00093

PubMed Abstract | Crossref Full Text | Google Scholar

21. Upasani A, Mariotto A, Eassa W, Subramaniam R. Robot-assisted reconstructive surgery of lower urinary tract in children: a narrative review on technical aspects and current literature. Transl Pediatr. (2023) 12(8):1540–51. doi: 10.21037/tp-22-533

PubMed Abstract | Crossref Full Text | Google Scholar

22. Moorthy K, Munz Y, Dosis A, Hernandez J, Martin S, Bello F, et al. Dexterity enhancement with robotic surgery. Surg Endosc Other Interv Tech. (2004) 18(5):790–5. doi: 10.1007/s00464-003-8922-2

PubMed Abstract | Crossref Full Text | Google Scholar

23. Harel M, Herbst KW, Silvis R, Makari JH. Objective pain assessment after ureteral reimplantation : comparison of open versus robotic approach. J Pediatr Urol. (2015) 11(2):82.e1–8. doi: 10.1016/j.jpurol.2014.12.007

PubMed Abstract | Crossref Full Text | Google Scholar

24. Smith RP, Oliver JL, Peters CA. Pediatric robotic extravesical ureteral reimplantation: comparison with open surgery. J Urol. (2011) 185(5):1876–81. doi: 10.1016/j.juro.2010.12.072

PubMed Abstract | Crossref Full Text | Google Scholar

25. Marchini GS, Hong YK, Minnillo BJ, Diamond DA, Houck CS, Meier PM, et al. Robotic assisted laparoscopic ureteral reimplantation in children: case matched comparative study with open surgical approach. J Urol. (2011) 185(5):1870–5. doi: 10.1016/j.juro.2010.12.069

PubMed Abstract | Crossref Full Text | Google Scholar

26. Casale P, Patel RP, Kolon TF. Nerve sparing robotic extravesical ureteral reimplantation. J Urol. (2008) 179(5):1987–90. doi: 10.1016/j.juro.2008.01.062

PubMed Abstract | Crossref Full Text | Google Scholar

27. Weiss DA, Shukla AR. The robotic-assisted ureteral reimplantation: the evolution to a new standard. Urol Clin North Am. (2015) 42(1):99–109. doi: 10.1016/j.ucl.2014.09.010

PubMed Abstract | Crossref Full Text | Google Scholar

28. Herz D, Fuchs M, Todd A, McLeod D, Smith J. Robot-assisted laparoscopic extravesical ureteral reimplant: a critical look at surgical outcomes. J Pediatr Urol. (2016) 12(6):402.e1–9. doi: 10.1016/j.jpurol.2016.05.042

PubMed Abstract | Crossref Full Text | Google Scholar

29. Grimsby GM, Dwyer ME, Jacobs MA, Ost MC, Schneck FX, Cannon GM, et al. Multi-institutional review of outcomes of robot-assisted laparoscopic extravesical ureteral reimplantation. J Urol. (2015) 193(5):1791–5. doi: 10.1016/j.juro.2014.07.128

PubMed Abstract | Crossref Full Text | Google Scholar

30. Dangle PP, Razmaria AA, Towle VL, Frim DM, Gundeti MS. Is pelvic plexus nerve documentation feasible during robotic assisted laparoscopic ureteral reimplantation with extravesical approach? J Pediatr Urol. (2013) 9(4):442–7. doi: 10.1016/j.jpurol.2012.10.018

PubMed Abstract | Crossref Full Text | Google Scholar

31. Arlen AM, Broderick KM, Travers C, Smith EA, Elmore JM, Kirsch AJ. Outcomes of complex robot-assisted extravesical ureteral reimplantation in the pediatric population. J Pediatr Urol. (2016) 12(3):169.e1–6. doi: 10.1016/j.jpurol.2015.11.007

PubMed Abstract | Crossref Full Text | Google Scholar

32. EAU Guidelines Office. Presented at the EAU Annual Congress Milan 2023. EAU Guidelines. Edn. prese. Arnhem, The Netherlands: EAU Guidelines Office (2023). Available online at: http://uroweb.org/guidelines/compilations-of-all-guidelines/ (Accessed October 07, 2024).

33. Gerber JA, Koh CJ. Robot-assisted laparoscopic ureteral reimplantation in children: a valuable alternative to open surgery. World J Urol. (2020) 38(8):1849–54. doi: 10.1007/s00345-019-02766-y

PubMed Abstract | Crossref Full Text | Google Scholar

34. Nguyen C, Bachtel H, Koh CJ. Pediatric robotic urologic surgery: pyeloplasty and ureteral reimplantation. Semin Pediatr Surg. (2023) 32(1):151264. doi: 10.1016/j.sempedsurg.2023.151264

PubMed Abstract | Crossref Full Text | Google Scholar

35. Molinaro F, Nascimben F, Todesco C, Fusi G, Chiarella E, Planchamp T, et al. Robotic approach to the uretero-vesical junction in children: an international multicentric retrospective study. Int J Med Robot Comput Assist Surg. (2023) 19:e2539. doi: 10.1002/rcs.2539

PubMed Abstract | Crossref Full Text | Google Scholar

36. Law ZW, Ong CC, Yap TL, Loh AH, Joseph U, Sim SW, et al. Extravesical vs. intravesical ureteric reimplantation for primary vesicoureteral reflux: a systematic review and meta-analysis. Front Pediatr. (2022) 10(October):935082. doi: 10.3389/fped.2022.935082

PubMed Abstract | Crossref Full Text | Google Scholar

37. Boysen WR, Akhavan A, Ko J, Ellison JS, Lendvay TS, Huang J, et al. Prospective multicenter study on robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV): outcomes and complications. J Pediatr Urol. (2018) 14(3):262.e1–6. doi: 10.1016/j.jpurol.2018.01.020

PubMed Abstract | Crossref Full Text | Google Scholar

38. Hajiyev P, Sloan M, Fialkoff J, Gundeti MS. The LUAA gundeti technique for bilateral robotic ureteral reimplantation: lessons learned over a decade for optimal (resolution, urinary retention, and perioperative complications) trifecta outcomes. Eur Urol Open Sci. (2023) 57:60–5. doi: 10.1016/j.euros.2023.09.006

PubMed Abstract | Crossref Full Text | Google Scholar

39. Boysen WR, Ellison JS, Kim C, Koh CJ, Noh P, Whittam B, et al. Multi-institutional review of outcomes and complications of robot-assisted laparoscopic extravesical ureteral reimplantation for treatment of primary vesicoureteral reflux in children. J Urol. (2017) 197(6):1555–61. doi: 10.1016/j.juro.2017.01.062

PubMed Abstract | Crossref Full Text | Google Scholar

40. Silay MS, Turan T, Kayalı Y, Başıbüyük İ, Gunaydin B, Caskurlu T, et al. Comparison of intravesical (Cohen) and extravesical (lich–gregoir) ureteroneocystostomy in the treatment of unilateral primary vesicoureteric reflux in children. J Pediatr Urol. (2018) 14(1):65.e1–4. doi: 10.1016/j.jpurol.2017.09.014

PubMed Abstract | Crossref Full Text | Google Scholar

41. Mittal S, Srinivasan A, Bowen D, Fischer KM, Shah J, Weiss DA, et al. Utilization of robot-assisted surgery for the treatment of primary obstructed megaureters in children. Urology. (2021) 149:216–21. doi: 10.1016/j.urology.2020.10.015

PubMed Abstract | Crossref Full Text | Google Scholar

42. Hendren WH. Operative repair of megaureter in children. J Urol. (1969) 101(4):491–507. doi: 10.1016/s0022-5347(17)62370-x

PubMed Abstract | Crossref Full Text | Google Scholar

43. Kansy J, Kotarbihska B, Clinics P, Academy M. Surgery of megaureters–modification of hendren’s operation. J Pediatr Surg. (1977) 12(2):183–8. doi: 10.1016/s0022-3468(77)80005-5

PubMed Abstract | Crossref Full Text | Google Scholar

44. Starr A. Ureteral plication. A new concept in ureteral tailoring for megaureter. Invest Urol. (1979) 17(2):153–8. PMID: 468516.468516

PubMed Abstract | Google Scholar

45. Weiss RM, Biancani P. Rationale for ureteral tapering. Urology. (1982) 20(5):482–7. doi: 10.1016/0090-4295(82)90118-2

PubMed Abstract | Crossref Full Text | Google Scholar

46. Toni T, Lombardo A, Andolfi C, Gundeti MS. Ureteroneocystostomy without ureteral remodeling for grade III–V vesicoureteral reflux treatment. J Pediatr Urol. (2021) 17(5):743.e1–7. doi: 10.1016/j.jpurol.2021.07.009

PubMed Abstract | Crossref Full Text | Google Scholar

47. Ben-Meir D, McMullin N, Kimber C, Gibikote S, Kongola K, Hutson JM. Reimplantation of obstructive megaureters with and without tailoring. J Pediatr Urol. (2006) 2(3):178–81. doi: 10.1016/j.jpurol.2005.05.010

PubMed Abstract | Crossref Full Text | Google Scholar

48. Barbour KW, Arunachalam P, King PA, McAndrew HF. The use of ureteral stents and suprapubic catheter in vesicoureteric reflux surgery. Pediatr Surg Int. (2004) 20(5):387–8. doi: 10.1007/s00383-004-1205-8

PubMed Abstract | Crossref Full Text | Google Scholar

49. Fichtenbaum EJ, Strine AC, Concodora CW, Schulte M, Noh PH. Tubeless outpatient robotic upper urinary tract reconstruction in the pediatric population: short-term assessment of safety. J Robot Surg. (2018) 12(2):257–60. doi: 10.1007/s11701-017-0722-0

PubMed Abstract | Crossref Full Text | Google Scholar

50. Rodriguez AR, Rich MA, Swana HS. Stentless pediatric robotic pyeloplasty. Ther Adv Urol. (2012) 4(2):57–60. doi: 10.1177/1756287211434927

PubMed Abstract | Crossref Full Text | Google Scholar

51. Silva MV, Levy AC, Finkelstein JB, Van Batavia JP, Casale P. Is peri-operative urethral catheter drainage enough? The case for stentless pediatric robotic pyeloplasty. J Pediatr Urol. (2015) 11(4):175.e1–5. doi: 10.1016/j.jpurol.2015.06.003

PubMed Abstract | Crossref Full Text | Google Scholar

52. Rappaport YH, Kord E, Noh PH, Koucherov S, Gaber J, Shumaker A, et al. Minimally invasive dismembered extravesical cross-trigonal ureteral reimplantation for obstructed megaureter: a multi-institutional study comparing robotic and laparoscopic approaches. Urology. (2021) 149:211–5. doi: 10.1016/j.urology.2020.10.018

PubMed Abstract | Crossref Full Text | Google Scholar

53. Visser IJ, van der Staaij JP, Muthusamy A, Willicombe M, Lafranca JA, Dor FJ. Timing of ureteric stent removal and occurrence of urological complications after kidney transplantation : a systematic review and meta-analysis. J Clin Med. (2019) 8:689. doi: 10.3390/jcm8050689

PubMed Abstract | Crossref Full Text | Google Scholar

54. Dey S, Raman VS, Peela T, Chand K, Chandra N. Sciencedirect comparison of outcomes between a 2 week versus 4 week stenting in pediatric pyeloplasty d A single centre observational study. Asian J Urol. (2020) 7:327–31. doi: 10.1016/j.ajur.2019.10.011

PubMed Abstract | Crossref Full Text | Google Scholar

55. Abdelwahab M, Abdelaziz A, Aboulela W, Shouman AM, Ghoneima W, Shoukry A, et al. One week stenting after pediatric laparoscopic pyeloplasty ; is it enough ? running title : short term stenting in pediatric pyeloplasty. J Pediatr Urol. (2019) 16:98. doi: 10.1016/j.jpurol.2019.10.016

Crossref Full Text | Google Scholar

56. Bustangi N, Kallas Chemaly A, Scalabre A, Khelif K, Luyckx S, Steyaert H, et al. Extravesical ureteral reimplantation following lich-gregoir technique for the correction of vesico-ureteral reflux retrospective comparative study open vs. laparoscopy. Front Pediatr. (2018) 6(December):388. doi: 10.3389/fped.2018.00388

PubMed Abstract | Crossref Full Text | Google Scholar

57. Akhavan A, Avery D, Lendvay TS. Robot-assisted extravesical ureteral reimplantation: outcomes and conclusions from 78 ureters. J Pediatr Urol. (2014) 10(5):864–8. doi: 10.1016/j.jpurol.2014.01.028

PubMed Abstract | Crossref Full Text | Google Scholar

58. Deng T, Liu B, Luo L, Duan X, Cai C, Zhao Z, et al. Robot-assisted laparoscopic versus open ureteral reimplantation for pediatric vesicoureteral reflux : a systematic review and meta-analysis. World J Urol. (2018) 36(5):819–28. doi: 10.1007/s00345-018-2194-x

PubMed Abstract | Crossref Full Text | Google Scholar

59. Kurtz MP, Leow JJ, Varda BK, Logvinenko T, Yu RN, Nelson CP, et al. Robotic versus open pediatric ureteral reimplantation : costs and complications from a nationwide sample. J Pediatr Urol. (2016) 12:408. doi: 10.1016/j.jpurol.2016.06.016

Crossref Full Text | Google Scholar

60. Bayne AP, Shoss JM, Starke NR, Cisek LJ. Single-Center experience with pediatric laparoscopic extravesical reimplantation : safe and effective in simple and Complex anatomy. J Laparoendosc Adv Surg Tech. (2012) 22(1):102–6. doi: 10.1089/lap.2011.0299

Crossref Full Text | Google Scholar

61. Baek M, Koh CJ. Lessons learned over a decade of pediatric robotic ureteral reimplantation. Investig Clin Urol. (2017) 58(1):3–11. doi: 10.4111/icu.2017.58.1.3

PubMed Abstract | Crossref Full Text | Google Scholar

62. Hamid R, Bhat NA, Baba AA, Mufti GN, Sheikh KA, Bashir MI. Primary obstructive megaureter in children ; 10 years’ experience from a tertiary care center. Urol Ann. (2022) 14:252–8. doi: 10.4103/UA.UA_77_20

PubMed Abstract | Crossref Full Text | Google Scholar

63. Babajide R, Andolfi C, Kanabolo D, Wackerbarth J, Gundeti MS. Postoperative hydronephrosis following ureteral reimplantation: clinical significance and importance of surgical technique and experience. J Pediatr Surg. (2023) 58(3):574–9. doi: 10.1016/j.jpedsurg.2022.07.002

PubMed Abstract | Crossref Full Text | Google Scholar

64. Sforza S, Cini C, Negri E, Bortot G, Maida D, Cito F, et al. Ureteral reimplantation for primary obstructive megaureter in pediatric patients. J Laparoendosc Adv Surg Tech A. (2021) 32(2):231–6. doi: 10.1089/lap.2021.0246

PubMed Abstract | Crossref Full Text | Google Scholar

65. He Y, Lin S, Xu X, He S, Xu H, You G, et al. Single-port-plus-one reimplantation in children with a. Front Pediatr. (2023) 11(November):1–8. doi: 10.3389/fped.2023.1238918

Crossref Full Text | Google Scholar

66. Chang C-L, Shei-Dei Yang S, Yang D, Hsu K, Chen H. Effectiveness of various treatment modalities in children with vesicoureteral reflux grades II–IV : a systematic review and network meta-analysis. BMJ Paediatr Open. (2023) 7:e002096. doi: 10.1136/bmjpo-2023-002096

PubMed Abstract | Crossref Full Text | Google Scholar

67. Jodal U, Smellie JM, Lax H, Hoyer PF. Ten-year results of randomized treatment of children with severe vesicoureteral reflux. Final report of the international reflux study in children. Pediatr Nephrol. (2006) 21:785–92. doi: 10.1007/s00467-006-0063-0

PubMed Abstract | Crossref Full Text | Google Scholar

68. Bilgutay AN, Kirsch AJ. Robotic ureteral reconstruction in the pediatric population. Front Pediatr. (2019) 7(MAR):1–10. doi: 10.3389/fped.2019.00085

PubMed Abstract | Crossref Full Text | Google Scholar

69. Zhou G, Jiang M, Yin J, Liu X, Sun J, Li S. Long-term, single-center study comparing open and laparoscopic procedures for congenital midureteral obstruction in children. Pediatr Surg Int. (2023) 39(1):1–7. doi: 10.1007/s00383-023-05494-y

Crossref Full Text | Google Scholar

70. Lu L, Bi Y, Wang X, Ruan S. Laparoscopic resection and End-to-End ureteroureterostomy for midureteral obstruction in children. J Laparoendosc Adv Surg Tech. (2017) 27(2):197–202. doi: 10.1089/lap.2016.0222

PubMed Abstract | Crossref Full Text | Google Scholar

71. Sun G, Yan L, Ouyang W, Zhang Y, Ding B, Liu Z, et al. Management for ureteral stenosis: a comparison of robot-assisted laparoscopic ureteroureterostomy and conventional laparoscopic ureteroureterostomy. J Laparoendosc Adv Surg Tech A. (2019) 29(9):1111–5. doi: 10.1089/lap.2019.0357

PubMed Abstract | Crossref Full Text | Google Scholar

72. Manjunath DA, Radhakrishna V, Vepakomma D. Transureteroureterostomy in children : a retrospective study. Am J Clin Exp Urol. (2021) 9(2):163–9. PMID: 3407984834079848

PubMed Abstract | Google Scholar

73. Biles AMJ, Finkelstein JB, Silva MV, Lambert SM, Casale P. Innovation in robotics and pediatric urology: robotic ureteroureterostomy for Duplex systems with ureteral ectopia. J Endourol. (2016) 30(10):1041–8. doi: 10.1089/end.2015.0645

PubMed Abstract | Crossref Full Text | Google Scholar

74. Leavitt DA, Rambachan A, Haberman K, DeMarco R, Shukla AR. Robot-Assisted laparoscopic ipsilateral ureteroureterostomy for ectopic ureters in children: description of technique. J Endourol. (2012) 26(10):1279–83. doi: 10.1089/end.2012.0041

PubMed Abstract | Crossref Full Text | Google Scholar

75. Lee NG, Corbett ST, Cobb K, Bailey GC, Burns AS, Peters CA. Bi-institutional comparison of robot-assisted laparoscopic versus open ureteroureterostomy in the pediatric population. J Endourol. (2015) 29(11):1237–41. doi: 10.1089/end.2015.0223

PubMed Abstract | Crossref Full Text | Google Scholar

76. Mattioli G, Lena F, Fiorenza V, Carlucci M. Robotic ureteral reimplantation and uretero-ureterostomy treating the ureterovesical junction pathologies in children: technical considerations and preliminary results. J Robot Surg. (2023) 17(2):659–67. doi: 10.1007/s11701-022-01478-7

PubMed Abstract | Crossref Full Text | Google Scholar

77. Zhu W, Zhou H, Cao H, Li P, Tao Y, Ma L, et al. Modified technique for robot-assisted laparoscopic infantile ureteral reimplantation for obstructive megaureter. J Pediatr Surg. (2022) 57(12):1011–7. doi: 10.1016/j.jpedsurg.2022.05.015

PubMed Abstract | Crossref Full Text | Google Scholar

Appendix 1. ERUS Survey questionnaire details

SECTION A—EXTRA-VESICAL ROBOTIC DISMEMBERED REIMPLANTATION (D-RALUR)A1—Indications

1. Patients treated for vesico-ureteral reflux (VUR)

2. Patients treated for obstructive megaureter

3. Patients treated for obstructive + refluxing megaureter

4. Patients treated for other indications (type and number)

A2—Patient Characteristics

5. Age at surgery (mean and range, years)

6. Weight at surgery (mean and range, kg)

7. Female patients

8. Male patients

A3—Operative Details

9. Unilateral operations

10. Bilateral operations

11. Duplex systems operated

12. Previous endoscopic bulking injection

13. Previous reimplantation (type and number)

14. Mean VUR grade (if applicable)

15. Robotic system used

16. Number of robotic trocars

17. Accessory laparoscopic trocar used?

18. Ureteral remodelling performed

19. Remodelling technique

20. Submucosal tunnel length (mean and range, cm)

21. Psoas hitch performed?

22. Pre-operative stent?

23. Intra-operative stent?

24. Stent removal timing

A4—Outcomes

25. Intra-operative complications (type and number)

26. Conversions to open surgery (number, indications)

27. Operative time (mean and range, min)

28. Follow-up duration (mean and range, months)

29. Bladder catheter duration (mean and range, days)

30. Length of hospital stay (mean and range, days)

31. VUR after surgery

32. UVJ obstruction after surgery

33. Resolved cases

34. Secondary surgeries (type and number)

35. Additional comments

SECTION B—EXTRA-VESICAL ROBOTIC NON-DISMEMBERED REIMPLANTATION (ND-RALUR)B1—Indications

36. Patients treated for VUR

37. Patients treated for other indications (type and number)

B2—Patient Characteristics

38. Age (mean and range, years)

39. Weight (mean and range, kg)

40. Female patients

41. Male patients

B3—Operative Details

42. Unilateral operations

43. Bilateral operations

44. Duplex systems operated

45. Previous bulking injection

46. Previous reimplantation (type and number)

47. Mean VUR grade

48. Robotic system used

49. Number of robotic trocars

50. Accessory laparoscopic trocar?

51. Number of ureteral remodelling

52. Remodelling technique

53. Submucosal tunnel length (mean, range)

54. Psoas hitch performed?

55. Pre-operative stent?

56. Intra-operative stent?

57. Stent removal timing

B4—Outcomes

58. Intra-operative complications

59. Conversions to open surgery

60. Operative time (mean and range, min)

61. Follow-up duration (months)

62. Bladder catheter duration (days)

63. Length of hospital stay (mean and range, days)

64. VUR after surgery

65. UVJ obstruction after surgery

66. Patients considered resolved

67. Secondary surgeries (type and number)

68. Additional comments

SECTION C—ROBOTIC URETERO-URETEROSTOMY (UU)C1—Indications

69. Ipsilateral UU for incontinence (duplex systems)

70. Ipsilateral UU for obstruction (duplex)

71. Ipsilateral UU for VUR (duplex)

72. Ipsilateral UU for obstruction + VUR (duplex)

73. Contralateral UU for incontinence (single systems)

74. Contralateral UU for obstruction (single)

75. Contralateral UU for VUR (single)

76. Contralateral UU for obstruction + VUR (single)

77. Other indications (type and number)

C2—Patient Characteristics

78. Age (mean and range, years)

79. Weight (mean and range, kg)

80. Female patients

81. Male patients

C3—Operative Details

82. Unilateral procedures

83. Bilateral procedures

84. Previous bulking injection

85. Previous reimplantation (type and number)

86. Previous UVJ surgeries (type and number)

87. Robotic system used

88. Number of robotic trocars

89. Accessory laparoscopic trocar?

90. Ureteral remodelling

91. Remodelling technique

92. Associated procedures (e.g., reimplantation) (type and number)

93. Pre-operative stent?

94. Intra-operative stent?

95. Stent removal timing

C4—Outcomes

96. Intra-operative complications (type and number)

97. Conversions to open surgery

98. Operative time (mean and range, min)

99. Follow-up duration (months)

100. Bladder catheter duration (days)

101. Hospital stay (days)

102. Anastomotic obstruction after surgery

103. Patients considered resolved

104. Secondary surgeries (type and number)

105. Additional comments