Background: Robotic surgery has become an effective extension of laparoscopy. The use of a robot may offer novel approaches to previously complex surgical dilemmas. Such is the case in our series of robotic assisted laparoscopic nephrectomy with contralateral ureteral reimplant. Typically, children with a refluxing non-functioning renal moiety in the setting of contralateral vesicoureteral reflux (VUR) require two relatively large incisions (and possibly two operations) to complete treatment. Our goal was to examine the safety and feasibility of a single robotic assisted procedure to deal with both a dysplastic renal moiety and contralateral VUR.
Methods: A retrospective review of 4 patients who underwent robotic assisted unilateral extravesical ureteral reimplantation (EVUR) with concurrent contralateral nephrectomy. Procedures were performed by a single surgeon using a robotic assisted laparoscopic approach. Two docking positions were used with four total ports. All renal moieties were removed through the umbilical port site. Antireflux surgery was performed using an extravesical technique. Operative time, length of stay, complications and follow up results were recorded in all 4 patients.
Results: All cases were completed laparoscopically without need for conversion to an open procedure. Mean patient age was 19 months. There were 3 males and 1 female. 3 patients had the pre-operative diagnosis of a nonfunctioning left kidney (L NFK) and right vesicoureteral reflux (R VUR). 1 patient had been diagnosed with a right duplication with a non-functioning lower pole (R NFLP) and left vesicoureteral reflux (L VUR). Mean operative time was 230 minutes. Mean length of stay was 2.5 days. There was one case of transient post-operative ureteral obstruction requiring 3 weeks of stenting. Follow up renal ultrasounds (RUS) and radionuclide cystograms were normal in all patients without evidence of hydronephrosis or reflux. Mean follow up time was 26 months.

Patient	Age (mos)	Diagnosis	Op time (min)	LOS (days)	Complications	F/U RUS/RNC	F/U time (mos)
A	6.6	L NFK/R VUR	188	2	None	Normal	28.6
B	21.5	L NFK/R VUR	196	2	None	Normal	28.6
C	11.5	L NFK/R VUR	224	3	ureteral obstruction	Normal	21.8
D	36.9	R NFLP/LVUR	310	3	None	Normal	25.5

Conclusions: Robotic assisted nephrectomy with simultaneous contralateral ureteral reimplant offers a novel approach to pathology that previously required two operations. In addition to reducing risks of anesthesia from a second procedure, children have smaller incisions and need not interrupt their normal schedules more than once.

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