Role of Robotics in the Management of Secondary Ureteropelvic Junction Obstruction

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

Disclosures

Int J Clin Pract. 2006;60(1):9-11. 

In This Article

Discussion

The application of laparoscopy and robotic-assisted techniques has allowed for minimally invasive, reconstructive surgery to mirror open surgical techniques. These techniques offer substantial benefits to patients by reducing morbidity, accelerating postoperative recovery and improving cosmetic outcome. Today, the da Vinci® robot is the most technologically advanced addition to the urologic surgery armamentarium. The advantages of the robot include tremor control, 1:5 motion scaling, six degrees of freedom within 1 cm of the tip of the end effector and three-dimensional vision resulting in simplified suturing and improved operative precision.

Clinical experience with RALP in adults has been previously reported.[3,4,5,6] Recently, Gettman and colleagues compared laparoscopic pyeloplasty performed with the da Vinci® robotic system vs. traditional laparoscopic techniques. They reported shorter overall operative and anastomotic times with the robotic approach.[7] Although studies of primary management of UPJO with the da Vinci® robot have been reported,[3,4,5,6,7] to our knowledge, no evaluation of secondary management of UPJO with RALP exists.

Robotic pyeloplasty may be a viable option in selected patients with recurrent UPJO after failed previous endoscopic or open surgical repair. Surgery for secondary pyeloplasty is often challenging because of fibrosis and adhesions in the region of the previously operated UPJ area. The degree of fibrosis is highly variable, which may be secondary to underlying healing factors in the patient as well as the amount of urine extravasation following the original therapy. Therefore, we found the average operative times to be 60 min longer in the secondary pyeloplasty group compared with primary cases (p < 0.05). Extra caution is advised on the right side because of the proximity of the inferior vena cava to the secondary UPJ side. In our series, the mean operative time was 279 min in secondary pyeloplasty patients. Recently, Sundaram et al. reported a 372-min operative time in their series of secondary UPJO managed by non-robotic laparoscopic pyeloplasty.[8]

In addition, the three-dimensional visualisation and magnification afforded by the robot allows for precise dissection; besides, there is no significant increase in blood loss, hospital stay or perioperative morbidity. An unobstructed drainage pattern was demonstrated in all patients of group 1 and group 2, with a mean follow-up of 10.7 and 13.5 months, respectively.

Our technique differs from previously reported techniques in two distinct areas. First, immediately preoperatively, an open-ended ureteral catheter is placed just distal to the UPJ allowing retrograde access to the ureter. The renal pelvis thus passively distends, facilitating intraoperative identification of the renal pelvis. The open-ended ureteral catheter also allows a guide wire to be passed into the collecting system and subsequent stent placement once the anastomosis is partially complete. Second, we place the fourth port for the bedside surgeon in a subxiphoid position.[9] After our initial two cases, a subxiphoid location was used for the fourth port, and this was found to be an ideal location for assistance in dissection, suctioning and intracorporeal introduction and removal of sutures. We believe that the advantage stems from the proximity of this port to the UPJ, the angle in which the UPJ is approached and minimal interference with the robotic instruments.

Today, the general consensus on the follow-up regimen after pyeloplasty is to perform a diuretic scan 3 months postoperatively. An unobstructed drainage in diuretic renography and/or IVP is accepted as success.[10] In our study, diuretic renography and/or IVP at approximately 3 months demonstrated unobstructed drainage in both groups. Despite being one of the larger series to date, we still have only limited numbers and follow-up. These patients will need long-term objective follow-up to evaluate for delayed failures.

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