Robotic Surgery in Pediatric Oncology: Lessons Learned from the First 100 Tumours. A Nationwide Experience

Background: The use of robotics has become commonplace in adult oncology but remains rare in paediatric oncologic surgery. We present the results of a large nationwide experience with robotic surgery in children with benign and malignant tumours. Methods: Prospective analysis (ClinicalTrials.gov NCT03274050) of robotic procedures performed between 2008 and 2019. Children received treatment according to the ongoing SIOP/SIOPEN protocols. Indications were approved by a certified tumour board. Findings: A total of 100 tumours were resected during 92 procedures in 87 children (56 girls). The median age at surgery was 7·4 years (3·5-12); 20% of children harboured germinal genetic alterations predisposing to cancer. Procedures were performed by laparoscopy for abdominal (71%) or pelvic tumours (10%) and by retroperitoneoscopy (5%) or thoracoscopy (14%). No intraoperative tumour rupture occurred during robotic-assisted dissection. Eight conversions (9%) to an open approach occurred. Neuroblastic tumour (n=29) was the main group (19 neuroblastomas, three ganglioneuroblastomas, seven ganglioneuromas). Renal tumour was the second largest group (n=24, including 20 Wilms’ tumours). The other 47 tumours were neuroendocrine (n=13), adrenal (n=11), pancreatic (n=3), germ-cell (n=7), thymic (n=4), inflammatory myofibroblastic (n=4) and five different rare tumours. Overall, 50 tumours were malignant, 2 were borderline and 48 were benign. The median hospital stay was 3 days (2-4). Five post-operative surgical complications occurred within the first 30 days in four patients. During a follow-up of 1 to 28 months, one child (Wilms’ tumour) presented pleural recurrence. One girl with Wilms’ tumour died of central nervous system metastasis. Interpretation: Robotic surgery for paediatric tumours is feasible and may be an option in highly selected cases. Indications should be discussed by tumour boards to avoid widespread and uncontrolled application of the approach. Children with genetic predisposition to cancer seem good candidates for the robotic approach. Trial Registration: ClinicalTrials.gov NCT03274050 Funding: The sponsor was Assistance Publique–Hopitaux de Paris (APHP, Clinical Research and Innovation Delegation) and this project was funded by a grant from Necker Hospital. Declaration of Interests: None to declare. Ethics Approval Statement: This prospective analysis received approval from institutional review boards and an independent ethics committee (Comite de Protection des Personnes, CPP Ile de France VII). The sponsor was Assistance Publique–Hopitaux de Paris (APHP, Clinical Research and Innovation Delegation).