By Beth Hanson
Pasquale Casale, MD, chief of pediatric urology, is an authority on robotic surgery for pediatric urologic problems, and he has developed many of the robotic procedures currently used. With the surgical robot, he treats obstructed kidneys, nonfunctioning bladders, and disorders of sexual development; he undertakes complex surgeries such as bladder neck reconstruction, bladder augmentation, and the creation of catheterizable channels—procedures that a lot of surgeons wouldn’t think of doing robotically, he says.
Dr. Casale recently operated on a 2-year-old girl who was incontinent because of an open bladder neck with bilateral renal duplication: bilateral ureteroceles and bilateral reflux. He and his team reconstructed the ureters, the continent mechanism of the bladder neck, and the rest of the bladder. The girl returned home two days after surgery without any catheters and is now fully continent.
To treat another patient, a 5-year-old girl with a duplicated kidney whose ureter emptied to her vagina, Dr. Casale and his team were able to reattach the ureter through three 5-mm incisions, making the child continent; she went home the same day.
Because the robotic approach is done through three small (5–8 mm) incisions instead of the single larger one typical of open surgery, patients develop fewer abdominal scars. Dr. Casale’s research has shown that incisions 1.5 cm or larger grow proportionately with the child, while incisions under 1.5 cm contract by 30 percent to 50 percent within two years.
In addition, the recovery period following robotic surgery is much shorter: Most kids go home within a 24-hour timeframe, compared with a week or so with open surgery. With bladder surgery, patients also have fewer bladder spasms after robotic surgery than open surgery. “They really return to their normal activities quite early,” says Dr. Casale.
Comparing open, laparoscopic, and robotic approaches, Dr. Casale details the advantages of the latter. The surgeon has as many degrees of freedom as during open surgery, but a digital magnification up to 12 times normal, compared with 3.5 times normal with open surgery, during which surgeons view the field through surgical loupes.
Robotic surgery is ergonomically different from open and laparoscopic surgery, Dr. Casale says. “You’re sitting down, you’re relaxed and comfortable, and you have degrees of freedom in arm and hand movement equivalent to open surgery. You get all the benefits of minimally invasive surgery, but with the ergonomic comfort that you don’t get in either of the other types of surgery.” Robotic surgery doesn’t entail the fatigue typically associated with laparoscopic and open surgery, which translates to better outcomes, in his opinion. With the option of a robotic surgical approach, patients, their families, and surgeons, too, have more choices and greater benefits, he says.
First published in Connections, the quarterly newsletter of Columbia Women’s and Children’s Health (Fall 2013)