Collaborating with our adult colleagues: A case series of robotic surgery for suspicious and cancerous lesions in children and young adults performed in a free-standing children's hospital

Abstract

Background: In adult urologic oncology the use of robotics has become commonplace; in pediatric urology it is rare. Herein, we describe a collaboration between an adult and a pediatric urologist performing robotic surgery for children and young adults with suspicious or cancerous genitourinary (GU) lesions.

Objectives: To evaluate clinical and oncologic outcomes in children and young adults undergoing robotic surgery for suspicious or cancerous lesions of the GU tract; to describe our collaborative model between an adult and pediatric surgeon at a free-standing children's hospital.

Design: We retrospectively reviewed all robotic cases performed at our institution from 2014 to 2016 for patients with a GU malignancy or a suspicious mass. The surgeries were performed by a pediatric urologist with robotic experience and a fellowship-trained MIS adult urologist specializing in oncology. Perioperative and oncologic outcomes were recorded.

Results: A total of eight robotic cases were performed: four partial nephrectomies (PN) with retroperitoneal lymph node dissection (LND) (OT 269-338 min, EBL 5-300 mL, LOS 3-6 days), one adrenalectomy with LND (6.4 cm mass; OT 172 min, EBL 5 mL, LOS 3 days), one nephrectomy with pericaval LND (9.8 cm mass; 234 min, EBL 25 mL, LOS 3 days), and two retroperitoneal LNDs (OT 572 and 508 min, EBL 250 and 100, LOS 3 and 4 days). Patient weights ranged from 14 to 79 kg (mean 53.4 kg). There were no major complications (Clavien 3-5). Pathology results for PN included papillary RCC (AJCC pT1aNx) and two cases of segmental cystic renal dysplasia with nephrogenic rests. Bilateral template RPLNDs yielded paratesticular rhabdomyosarcoma (43 nodes; COG low risk group II stage I) and mixed non-seminomatous germ cell tumor (74 nodes; COG stage III). The nephrectomy yielded an undifferentiated sarcoma, low grade; the adrenalectomy favorable-type ganglioneuroma.

Discussion: In pediatrics, urologic oncology cases are often managed with open surgery. Our series demonstrates the feasibility of using the robotic approach in carefully selected cases. In doing so, the patient benefits from a minimally invasive surgery, while the surgeon benefits from robotic surgical dexterity. We seamlessly advanced these new techniques through a step-wise collaboration between an adult urologist who routinely performs robotic oncology procedures and a pediatric urologist experienced in robotics for benign conditions.

Conclusion: In this small series, we safely and effectively adapted adult robotic techniques for genitourinary oncology cases in children and young adults.

Keywords: Adrenalectomy; Oncology; Partial nephrectomy; Radical nephrectomy; Retroperitoneal lymph node dissection; Robotics.

Figure 1

Enlarging aortocaval lymph node in a 17-year-old male with a history of mixed NSGCT managed initially with orchiectomy and surveillance.

Figure 2

(A) Coronal and cross-sectional CT imaging with contrast of an adrenal mass in a 7-year-old boy with elevated urine catecholamines. (B) Cross-sectional T2 MRI imaging demonstrating suspicious cyst wall abnormalities in a 19-year-old girl found to have unclassified spindle cell carcinoma.

Figure 3

Adult to pediatric port placement for right robotic partial nephrectomy. (A) Adult port placement. (B) Pediatric port placement (14-kg patient). (C) View of hilar clamping during partial nephrectomy in a 14-kg girl.

Figure 4

Adult to pediatric port placement for right robotic adrenalectomy. (A) Adult port placement. (B) Pediatric port placement (31-kg patient). (C) View of the adrenal vein prior to transection in a 31-kg boy undergoing adrenalectomy.

Figure

View of renal hilum during partial nephrectomy in a 14-kg girl.