Robotic dismembered pyeloplasty for a left side ureteropelvic junction obstruction

The introduction of the Da Vinci Surgical System to perform complex reconstructive procedures, such as repair of ureteropelvic junction obstruction, has helped to overcome some of the technical challenges associated with laparoscopy. We show our technique for robotic dismembered pyeloplasty for a left side ureteropelvic junction obstruction in a 54-year-old woman.

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Robotic dismembered pyeloplasty for a left side ureteropelvic junction obstruction

Authors

T Piéchaud, F Annino

Abstract

The introduction of the Da Vinci Surgical System to perform complex reconstructive procedures, such as repair of ureteropelvic junction obstruction, has helped to overcome some of the technical challenges associated with laparoscopy.
We show our technique for robotic dismembered pyeloplasty for a left side ureteropelvic junction obstruction in a 54-year-old woman.

Classification

complex cases, robotic

Keywords

Robotic dismembered pyeloplasty, left side ureteropelvic junction obstruction

Media type

Surgical video

Duration

19'20''

Publication

2009-02

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E-publication

WeBSurg.com, Feb 2009;9(02).
URL: http://www.websurg.com/doi-vd01en2546.htm

Robotic dismembered pyeloplasty for a left side ureteropelvic junction obstruction

1. Trocar placement 00'27''

The ports are placed as shown. The first 12mm port, for the optic is placed at the pararectal line at the level of the umbilicus. Two robotics ports are placed at the left mammary line, one caudally to the costal arch, and one on the left iliac fossa. Two 5mm laparoscopic ports are placed, for the assistant, in the left iliac fossa as shown.

2. Patient\'s position 00'54''

The patient is placed in a lombotomic position, and the robotic system comes from the back of the patient.

3. Assistant\'s position 01'26''

The assistant is working on the right side of the camera and the scrub nurse is on his right side. The screen is placed at the head of the patient and it allows the assistant to work in a comfortable way. There are no conflicts, nor external or internal.

4. Incision of left Toldt\'s line 01'43''

The surgery begins with the incision of the left Toldt’s line and with the mobilization of the left colon.

5. Colon mobilization 02'11''

Once the peritoneum is incised, the dissection continues with the medialization of the colon in order to identify the gonadal vein and the left ureter.

6. Left gonadal vein identification 02'35''

The left gonadal vein is identified and the dissection continues cranially and medially to reach the left lumbar ureter.

7. Ureter identification and isolation 03'31''

The ureter is identified and gently isolated, avoiding its skeletonization. The left ureter is clearly visible and minimally isolated.

8. Gonadal vein medialization 03'54''

The gonadal vein is medialized in order to have a larger exposure of the ureteropelvic junction. The dissection continues cranially in order to better identify the pelvis.

9. Renal pelvis isolation 04'23''

The renal pelvis is identified and isolated. The robotic assistance allows the surgeon to perform a precise minimal dissection, reducing the de-vascularization of the structures. It presents a vascular structure passing behind the junction.

10. Ureteropelvic junction dissection 04'48''

The ureteropelvic junction is prepared and dissected from the surrounding tissues.

11. Ureter division 05'07''

The ureter is divided.

12. Removal of ureteropelvic junction and ureter spatulation 05'23''

The redundant renal pelvis is transected and the ureteropelvic junction is removed. The ureter is spatulated.

13. Reconstruction 05'53''

The reconstruction is performed using a 4/0 Monocryl suture, 17mm half-circle VISI-BLACK needle. Three separated sutures are placed between the ureteral posterior corner and the distal part of the renal pelvis. The stitches are passed outside-inside in the renal pelvis, then inside-outside in the ureter. The Endo-wrist of the robotic system is very useful in this step of the procedure and allows the surgeon to place the sutures with extreme precision. The renal pelvis is reduced by beginning on its cranial edge.

14. Hydrophilic guide insertion 07'27''

A soft hydrophilic guide wire is inserted in the abdomen through an assistant port. Then it is introduced in the ureter until the bladder is reached.

15. Double-J ureteral catheter insertion 07'46''

A double-J ureteral catheter is inserted on the guide wire and placed in the ureter. Thanks to the robotic assistance, this maneuver is easier compared to the laparoscopic approach.

16. Completion of reconstruction 07'59''

The reconstruction is completed by a running suture.

17. Postoperative outcome 08'08''

The patient was discharged 2 days after surgery without complications. The ureteral stent was removed after 1 month. The introduction of robotic technology for complex reconstructive surgery may help to reduce some of the limitations associated with laparoscopy by offering a magnified 3-Dimensional view, eliminating tremor, enhancing surgeon comfort, and increasing the ability to mimic genuine hand and wrist movements.