A Novel Approach to Pediatric Nephrectomy

Pediatric urologists at Cleveland Clinic continue expanding the successful techniques used in adult patient populations to their pediatric patients. A low anterior access (LAA) approach for pediatric nephrectomy using the single-port (SP) robot is the latest innovation attracting attention within the field.

Julie Klock, MD, a urology resident, along with staff pediatric urologists Jessica Hannick, MD, and John (Jack) Weaver, MD, presented an award-winning video abstract at the 2025 Annual American Urological Association Meeting in Las Vegas that describes the technique and its advantages.

What is low anterior access?

LAA is a novel approach that utilizes one small inguinal incision and allows for access directly into the retroperitoneal space. Cleveland Clinic urologists have previously combined the LAA approach with the SP robot for pediatric pyeloplasties and have now applied this technique to pediatric nephrectomy.

“The SP robotic system allows us to regionalize surgeries further and avoid the intraperitoneal space,” says Jihad Kaouk, MD, Chair of the Department of Urology at Cleveland Clinic. “With the addition of LAA, we can spare upper abdominal muscles, improve cosmesis, and decrease postoperative pain, creating a better perioperative and postoperative experience for our patients.”

Under the direction of Dr. Kaouk, Cleveland Clinic was the first to report using LAA with the SP robot for adult pyeloplasty and retroperitoneal partial nephrectomy.

Simple nephrectomy: Now and then

Approaches to simple nephrectomy have evolved significantly in the past decade. Prior to minimally invasive techniques, surgeons performed open surgery using a large flank incision near the ribs. The incision penetrated various muscle layers and was likely to result in significant postoperative pain leading to prolonged recovery.

The advent of robotics ushered in smaller incision access points through the abdominal wall, resulting in one to four incisions up to 1 cm each. The combination of the SP robot and LAA approach took this one step further, affording surgical access with a single 2.5 cm to 3 cm, lower abdominal incision. Cleveland Clinic urologic surgeons familiar with the technique note that it heals well and has better cosmesis. Patients also report excellent postoperative pain control.

While the pediatric experience is relatively new, in adult patients, the LAA approach in SP urologic surgeries is reducing and—in many cases—eliminating the need for postoperative opioids, according to multiple reports and extensive Cleveland Clinic experience.

Patients are going home earlier, too. Depending on age and other timing factors, same-day surgery is often possible.

Dr. Hannick notes that ideal candidates are at least 18 months old, weigh more than 10 kgs, and are indicated for a kidney or ureteral surgery.

Takeaways for pediatric urologists

Dr. Hannick says that most urologists are trained to do robotic surgery using the multiport approach, and, understandably, there is a learning curve with any new technique. She adds that building a practice that includes the SP and LAA approach in children requires institutional and nursing support as well as a mentor/preceptor in adult general urology or urologic oncology.

“As with many new technical modalities, for now, the adult urology population is where most pediatric urologists will be learning these advanced techniques. When embarking on an SP robotic practice, observe cases, participate in simulations, and then start with proctored cases until you get comfortable,” concludes Dr. Hannick.