Role of Robotics in the Management of Secondary Ureteropelvic Junction Obstruction

Fatih Atug; Scott V. Burgess; Erik P. Castle; Raju Thomas


Int J Clin Pract. 2006;60(1):9-11. 

In This Article

Materials and Methods

Between November 2002 and April 2005, 44 patients with UPJO underwent RALP at our institution using the da Vinci® robotic system by the same surgical team. Of these, seven patients were referred following failed surgery for UPJO. Four patients had undergone previous retrograde endopyelotomy. Two patients had one prior open pyeloplasty. One patient underwent two prior open pyeloplasties and a retrograde endopyelotomy. The patients were evaluated in two groups. The first group consisted of primary pyeloplasty patients (group 1), and the second group consisted of secondary pyeloplasty patients (group 2). A retrospective chart review was performed, and variables analysed included total operative time, length of hospital stay (LOS), estimated blood loss (EBL) and success rates. These factors were compared between the primary and secondary robotic pyeloplasty cases. The Student's t-test was used for statistical analysis.

In addition to signs and symptoms of obstruction, all patients had radiographic evidence of UPJO on diuretic renography or excretory urography [intravenous pyelogram (IVP)]. All patients underwent cystoscopy with retrograde pyelography to confirm UPJO and ureteral catheter placement at the start of the procedure.

Patients were placed in a modified 45-degree lateral decubitus position (Figure 1). A standard 12-mm umbilical port was placed, and the remaining two 8-mm robotic ports were placed under direct vision using the laparoscope. A 12-mm assistant port was placed in subxiphoid position. The colon was reflected and the kidney approached. These seven patients had significantly more fibrosis and adhesions as compared with the primary pyeloplasty group. Meticulous dissection, though tedious, was accomplished with the da Vinci™ Robot. Both the zero- and 30-degree stereoscopic lenses were used, as needed, to ensure optimum visualisation of the UPJ area.

Patient's positioning and robot docked for right-side ureteropelvic junction obstruction. The patient is placed in 45-degree lateral decubitus position. Red arrow shows the camera in place.

Anderson-Hynes pyeloplasty was performed in all patients. Stay sutures were placed on the ureter and renal pelvis for traction and orientation. The UPJO was then transected, the ureter was spatulated, and any redundant renal pelvis was excised. The posterior anastomosis was completed first using 4-0 polyglactin sutures on an RB-1 needle. Prior to completing the anastomosis, the bedside surgeon places a double-pigtail stent over a guide wire that is passed through an open-ended catheter placed in the ureter. The pyeloplasty was completed using running 4-0 polyglactin sutures for the anterior anastomosis. The UPJ was allowed to drop back into the renal bed, and the proximal ureter and pelvis were inspected to ensure no kinking before desufflating the abdominal cavity. A closed surgical drain was placed through one of the trocar sites. The fascia and skin were closed in standard fashion. The bladder was drained with a standard Foley catheter. The double-pigtail stent was left indwelling for approximately 6 weeks. At 3-month follow-up, objective assessment of the repair was performed with diuretic renography and/or IVP.


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