Robot-Assisted Pyeloplasty

Abstract

Ureteropelvic junction obstruction (UPJO) is defined as a significant, functional alteration in the “transit” of urine due to an intrinsic or extrinsic obstruction at the junction between the ureter and the renal pelvis. In the majority of cases, its origin is congenital. UPJO is the most common congenital abnormality of the ureter, with an annual reported incidence of 5/100,000 (Eden CG, Eur Urol 52(4):983–989, 2007). Patients may present with pain, renal calculus disease, infection, hypertension; or any combination of the above. The goal of reparative surgery is to alleviate symptoms (pain, hypertension) and to preserve renal function. Delayed transit without symptoms or functional loss can be observed in many cases. Historically, open pyeloplasty has been the standard treatment for UPJO, with success rates of 90–100% (Notley RG, Beaugie JM, Br J Urol 45(5):464–467, 1973; Persky L, Krause JR, Boltuch RL, J Urol 118(1 Pt 2):162–165, 1977; Brooks JD, Kavoussi LR, Preminger GM, Schuessler WW, Moore RG, Urology 46(6):791–795, 1995). However, dissatisfaction with the consequences of the flank incision used to perform open pyeloplasty has led to the development over the past 2 decades of minimal invasive alternatives to open surgery in the form of endopyelotomy, balloon disruption of the UPJ, and, more recently, minimally invasive pyeloplasty. The first reconstructive procedure done to the renal pelvis which involved the transection of the ureter and its anastomosis to the renal pelvis was performed successfully in 1892. Subsequently, open surgical techniques were developed, the most popular being the Anderson-Hynes dismembered pyeloplasty in 1949; Foley in 1937 (Y-V plasty), and Scardino-Prince in 1953 (flaps) (Pereira Arias JG, Gamarra Quintanilla M, Gallego Sanchez JA, Camargo Ibergaray I, Astobieta Odriozola A, Ibarluzea Gonzalez G, Arch Esp Urol 60(4):449–461, 2007). In 1992 the introduction of laparoscopic surgery for the kidney revolutionized the way UPJO was managed. Laparoscopic pyeloplasty was first performed in 1993 and has been associated with success rates equivalent to those reported for open UPJO repair (Schuessler WW, Grune MT, Tecuanhuey LV, Preminger GM, J Urol 150(6):1795–1799, 1993; Kavoussi LR, Peters CA, J Urol 150(6):1891–1894, 1993) with improved postoperative convalescence. Robotic pyeloplasty was first performed by Sung in 1999 and has been widely adopted in many centers as an equally effective option (Sung GT, Gill IS, Hsu TH, Urology 53(6):1099–103, 1999). All types of pyeloplasty may be performed using the da Vinci^® Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA), including Anderson-Hynes pyeloplasty, Y-V-plasty, and non-dismembered pyeloplasty (Yanke BV, Lallas CD, Pagnani C, Bagley DH, J endourology Endourological Soc 22(6):1291–1296, 2008; El-Shazly MA, Moon DA, Eden CG, J endourology Endourological Soc 21(7):673–678, 2007). The purpose of this chapter is to help the reader understand the indications and technical steps involved in performing robot-assisted pyeloplasty. We review the technical features, results, and comparative studies of the robotic pyeloplasty from the available medical literature (Table 12.1). Although there are nuances of the procedure that may differ from institution to institution, we have attempted to review the steps performed at the University of Miami where the conventional laparoscopic repair preceded the advent of robotic technology by several years.

This chapter contains a video segment which can be found at the URL: http://www.springerimages.com/Su