Robotic dismembered pyeloplasty for the treatment of ureteropelvic junction obstruction.

• Main Author: Vipul Patel
• Format: Article
• Language: English
• Published: Wolters Kluwer Medknow Publications 2005-01-01
• Series: Indian Journal of Urology
• Subjects: Robotic; Pyeloplasty; Ureteropelvic junction obstruction
• Online Access: http://www.indianjurol.com/article.asp?issn=0970-1591;year=2005;volume=21;issue=2;spage=97;epage=101;aulast=Patel
• ISSN: 0970-1591; 1998-3824

Objective: Laparoscopic pyeloplasty has been shown to have equivalent surgical outcomes with less surgical morbidity when compared to the open approach. The laparoscopic approach has traditionally been performed in a few specialized training centers because of the advanced technical skills required to perform this complex reconstructive procedure. The introduction of robotic technology into the modern day operating suite has brought on a new era and has simplified complex urologic reconstructive procedures. The daVinci robot provides the advantages of three-dimensional vision, magnification, and a robotic articulating wrist. These features allow precise dissection and suturing capabilities. We used the daVinci robot to perform robotic assisted laparoscopic pyeloplasty. We studied its feasibility, utility, and efficacy. Methods: Between July 2002 and April 2003, 12 patients with a mean age of 29.2 years (16-56) underwent robotic assisted laparoscopic dismembered pyeloplasty. Each patient had presented with flank pain (six left and right) and had been diagnosed with a ureteropelvic junction (UPJ) obstruction by either IVP or MAG3 renal scan. A retrograde pyelogram was performed preoperatively to delineate the anatomy and a stent was placed. Robotic dismembered pyeloplasty was performed. Eight of 12 patients had crossing vessels only five of which were shown on preoperative CT scan. The crossing vessels were preserved in all cases. The UPJ was dismembered at the point of obstruction and the scar excised. The ureter was spatulated medially and the renal pelvis fashioned appropriately. Ureteropelvic reconstruction was performed with eight-interrupted 4-0 monocryl sutures on an RB-1 needle in the first five cases. In the other seven cases the anastomosis was performed with two running semicircular sutures. Stents were removed at 14-28 days. An IVP was performed prior to stent removal and a renal scan at 3 and 6 months. Results: Each patient underwent a successful procedure without open conversion, transfusion or complication. Estimated blood loss was minimal at 52 cm3. Each patient was discharged home on the first postoperative day, average 18 h. Operative times fell quickly as experience with the daVinci robot increased. Operative time averaged 201 min. The first five patient′s average or time was 262 vs. 158 min for the last seven. Time for the anastomosis averaged 42 min (100-20). The initial five cases were performed with an interrupted anastomosis. These took longer averaging 65.4 min (100-33). The subsequent seven cases were performed with two running hemi-circumferential stitches with anastomotic time averaging 25 min (30-20). Intraoperatively no complications were noted. Postoperatively the average hospital stay measured from the time of surgery to the time of discharge averaged 18 h (24-16). No postoperative complications have been noted. Average return to work is 10.9 days, and clearance for full activity at 17 days. Duration of the stent has averaged 18 days (24-13). The initial five patients with the interrupted anastomosis had longer stent times of 22.2 days (28-17) while the patients with a running anastomosis has average stent times of 17.6 days (22-13). Average follow up is currently 4.9 months (2-10). Each patient is doing well with no signs of recurrent obstruction. Follow up has been documented with MAG3 renal scan with Lasix at 3, 6 and 9 months. Conclusion: The adoption of robotic technology into today′s modern operating rooms has stimulated a new era in urologic surgery. The daVinci robot provides magnified three-dimensional vision and a miniature robotic articulating wrist that allows precise dissection and laparoscopic suturing. Robotic dismembered pyeloplasty is an excellent technique with very good results. As experience with the robotic instrumentation increases operative times fall quickly. Blood loss and pain are minimal, allowing early discharge home and quick recovery. The short-term results are promising. Longer follow-up is needed.