Introduction R General considerations about vesicoureteric reflux 32 4 30 31 2 10 16 Traditional surgical techniques in the treatment of VUR 12 6 11 13 25 14 21 27 8 R 20 All these facts and tendencies mentioned above in turn suggest that, at least for the foreseeable future, there will remain a group of patients in whom STING is deemed-or proves to be-insufficient. Open surgery on the other hand has its drawbacks as well due to its invasiveness. In an ideal world physicians would be able to define very precisely and at the earliest possible point in time which group of patients with VUR is at increased risk for the complication of pyelonephritic scarring and which group is not. This would in turn allow a very tailored approach to each individual child with pre-emptive surgical measures in the group at risk. Failing this knowledge, the next best thing to aim for is to combine the superior results of time-honoured open procedures like a Cohen reimplantation or Lich-Gregoir operation with the much sought after minimal invasiveness of laparoscopy, possibly with the added ultra-precise tissue handling and dexterity of robotic surgery. These considerations are the driving force of the developments described in this text. Conventional laparoscopic techniques 7 17 19 28 1 12 33 18 5 26 http://www.espu.org Robot-assisted techniques R 3 23 24 1 Fig. 1 Outside view once the draped robotic arms are connected to the laparoscopic ports: the child seems completely “embraced” by the machine  Extravesical technique 2 3 Fig. 2 Extravesical approach: very gently the detrusor muscle is incised and peeled away until the delicate bladder mucosa starts to bulge  Fig. 3 Extravesical approach: the completely freed ureter is hinged into the trough to create an anti-reflux valve mechanism  3 9 29 23 Intravesical technique R 22 3 24 4 Fig. 4 Intravesical approach: creation of the submucosal tunnel connecting the periureteral incisions. (The jaws of the forceps measure 5 mm in length)  3 18 24 Peters and Callewaert each reported one case of persisting low-grade reflux in their initial experience. Unlike the situation in open surgery, bladder spasms remained completely absent and anticholinergics were unnecessary. This fact is highly suggestive of the minimal invasiveness and limited trauma incurred by the bladder wall. When comparing the robotically assisted intra- and extravesical operations it is our impression that the Lich-Gregoir technique offers some advantages over the intravesical operation: no need for catheters, no haematuria and easier reproducibility. The drawback is that the abdominal cavity needs to be entered. The abdominal cavity even in smaller children is large enough to allow comfortable movement of the instruments, whereas intravesical operations in this patient group can be technically impossible due in part to the relative bulkiness of the robotic instruments. Conclusion Treatment modalities of reflux are evolving rapidly. Conventional or robot-assisted laparoscopic techniques must be considered a possible future alternative to the more traditional ways of treating this condition. There is no proven superiority at this time and experience is limited to a few centres only and relatively small numbers of patients. It is well established that with open surgery very high success rates can be achieved and that morbidity is relatively low and hospitalisation nowadays can be kept short. The first impressions are that morbidity using laparoscopic techniques is lower still and that there is some cosmetic gain, but it is obvious that the most important issue will be whether the long-term success rates are at least comparable. Most surgeons agree that robotics certainly add to the precision and ease of the individual surgical steps when compared to conventional laparoscopy, but the financial costs are very high. The intravesical approach using robotics is feasible, but technical difficulties must be taken into account in smaller children. (The same holds true for the conventional laparoscopy.) The extravesical robotic approach clearly seems the more promising, possibly even after failed submucosal injection therapy. Nevertheless we feel that the intravesical approach deserves further pursuing because it may allow surgical correction of other malformations at the level of the bladder neck and ureterovesical junction in a minimally invasive and very precise way. It would be premature to promote laparoscopy as the golden mean between STING and open surgery for a subgroup of reflux patients at this point, as this would imply diverting a large number of patients to a few centres where either the technical laparoscopic expertise or a robotic system is available. However, we remain convinced that in the (near) future laparoscopy will find its place in the care for these patients.