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Edward C. Diaz, MD, with the da Vinci Xi Surgical System at CHLA
Q&A: Advancing Robotic Surgery in Pediatric Urology
CHLA’s newest urologic surgeon talks about robotic surgery advances, the biggest challenge in pediatrics, and what the future may hold.
For nearly two decades, Children’s Hospital Los Angeles has been among the highest-volume centers in the country for robotic surgery in children—performing approximately 850 robot-assisted surgeries since 2008.
Pediatric Urologic Surgeon Edward C. Diaz, MD, is one of the many surgeons at CHLA with extensive training and experience in these procedures. Dr. Diaz joined Children’s Hospital Los Angeles in 2023. He completed urology residency at the Glickman Urological and Kidney Institute at Cleveland Clinic and a pediatric urology fellowship at Lurie Children’s Hospital. Prior to joining CHLA he served as an attending pediatric urologist at Lucile Packard Children’s Hospital/Stanford University and Advocate Children’s Hospital in Chicago.
Dr. Diaz shares how CHLA’s Urology team uses the da Vinci Xi Surgical System, the unique challenges surgeons face with pediatric patients—and how he sees the future.
What are the advantages of robotic-assisted surgery in urology?
The key advantage is that incisions are smaller and dissection of the abdominal wall layers, including musculature, is less compared to traditional open surgery. Using a minimally invasive approach (laparoscopic/robotic) has been shown to speed recovery, lessen pain, and shorten hospital stays for patients.
Depending on the habitus of the patient or targeted anatomy, using a laparoscopic/robotic approach may sometimes offer better visualization of the target anatomy compared to traditional open surgery.
Robotic surgery is an evolution of laparoscopic surgery. Advantages to robotic surgery over laparoscopy include surgeon control of the camera and 360-degree wristed motion that wasn’t possible otherwise.
At CHLA, we use the robot mostly for urinary tract reconstructions. In urology, our most common robotic procedures include pyeloplasty, ureteroureterostomy, ureteral reimplantation, and Mitrofanoff procedures.
What is the biggest challenge with robotic surgery in children?
Today’s surgical robots are primarily designed for adults, and as pediatric surgeons the biggest challenge is adapting to using the equipment in smaller spaces.
There is a debate in the field about how far to push the envelope in terms of a child’s age and size. But the reality is that multiple 8-millimeter incisions on a small baby are not minimally invasive and having an ideal amount of space in for optimal function of the robotic arms is always a big consideration.
How do you handle that challenge?
Patient selection is key. At CHLA, our focus is on doing safe robotic surgery. Our group has extensive experience with these procedures, and we weigh the benefits and risks very carefully.
For most urologic robotic surgeries, we look at children over 10 kilos, or 22 pounds. With today’s technology, it often makes more sense to do a traditional open surgery on a patient smaller than that, depending on the procedure.
Edward C. Diaz, MDOur large volume and long history of robotics have resulted in a robust clinical data set that has been helpful in assessing outcomes and ways to improve our technique.
Why is CHLA an ideal place for pediatric robotic surgery?
Our biggest strength is the experience of our team. Not just the surgeons, but the entire team—from scrub techs to nurses—knows how all the robotic pieces work. Not many children’s hospitals have a dedicated pediatric robotics team, and that is a huge advantage.
CHLA also has an excellent relationship with the manufacturer of these robots, Intuitive. That gives us access to the newest equipment and accessories, which allows us to perform our procedures with the latest technology available.
Our large volume and long history of robotics have also resulted in a robust clinical data set that has been helpful in assessing outcomes and ways to improve our technique. For example, we recently had an abstract accepted to the American Urological Association national meeting looking at our outcomes for pyeloplasty. This included more than 350 robotic pyeloplasties over the last 15 years.
How do you see the future?
We will see the implementation of autonomous machines and AI-assisted robotic systems in the next decade. And while a lot depends on industry, which so far has been focused on adults, urology residency and training programs have gone to using more minimally invasive approaches for the surgical treatment of urologic diseases. I think the newer and younger generation of surgeons is going to continue pushing this technology further for pediatric patients and developing new applications.
The challenge will be to make sure we are truly making outcomes better for patients. That’s particularly important because robotic surgery tends to cost more than traditional open surgery. I think those costs will continue to come down, but it’s critical that we focus on providing the best care for patients, no matter which approach we use.