How to Decide Which Infant Can Have Robotic Surgery? Just Do the Math

Background: In pediatric urology, robot-assisted surgery has overcome several impediments of conventional laparoscopy. However, workspace has a major impact on surgical performance. The limited space in an infant can significantly impede the mobility of robotic instruments. There is currently no consensus on which infant can undergo robotic intervention and no parameters to help make this decision, especially for those surgeons at the start of their learning curve.

Objective: We sought to evaluate our experience with infants to create an objective standard to determine which patients may be most suitable for robotic surgery.

Study Design: We prospectively evaluated 45 infants (24 males, 21 females), aged 3-12 months old, who underwent a robotic intervention for either upper or lower urinary tract pathology. At the preoperative office visit the attending surgeon measured the distance between both anterior superior iliac spines (ASIS) as well as the puboxyphoid distance (PXD), regardless of whether the approach was for upper or lower tract disease. Patients' weights were also noted. During surgery, we recorded the number of robotic collisions as well as console time. All surgeries were performed utilizing the da Vinci Si Surgical System by a single surgeon.

Results: There were no differences in ASIS, PXD, collisions or console time when stratified by gender, age or weight. When arranging by upper or lower tract approach, there was no difference in the number of collisions. There was a strong inverse relationship between both ASIS distance and PXD and the number of collisions. Additionally, there was a strong correlation between the number of collisions and console time (Fig. 1). Using a cutoff of 13 cm for the ASIS, there were significantly fewer collisions in the >13 cm group as compared to the ≤13 cm group. This was also true for the PXD using a cutoff of 15 cm: there were significantly fewer collisions in the >15 cm group as compared to the ≤15 cm group.

Discussion: Safe proliferation of robotic technology in the infant population is, in part, dependent on careful patient selection. Our data demonstrated a reduction in instrument collisions and console time with increasing anterior superior iliac spine and puboxyphoid distances. Neither age nor weight was correlated with these measurements, the number of instrument collisions or console time. Limitations include that this is a single institution study with all infants being operated on by a single surgeon. Therefore, the findings of this study may not be generalizable to a less experienced surgeon. Yet, we believe that ASIS and PXD measurements can be used as a guide for the novice surgeon who is beginning to perform robotic-assisted surgery in infants.

Conclusion: We found that surgeon ability to perform robotic surgery in an infant is restricted by collisions when the infant has an ASIS measurement of 13 cm or less or a PXD of 15 cm or less. Objective assessment of anterior superior iliac spine and puboxyphoid distance can aid in selecting which infants can safely and efficiently undergo robotic intervention with a minimum of instrument collision, thereby minimizing operative time.