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Robotic-Assisted Laparoscopic Pyeloplasty Periprocedural Care

  • Author: Chandru P Sundaram, MD; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Jul 07, 2016
 

Patient Education and Consent

After the decision has been made for surgical intervention, the patient should be counseled on all the options available for the treatment of ureteropelvic junction obstruction (UPJO), including endopyelotomy, laparoscopic pyeloplasty, robotic-assisted laparoscopic pyeloplasty (RLP), and open pyeloplasty. The risks and benefits of each procedure should be carefully explained to allow the patient to come to an informed decision.

In the case of RLP, the patient should receive information about the procedure, the possible perioperative complications, and the anticipated postoperative course, as well as about the placement of a ureteral stent and the possible discomfort associated with it. The surgeon should inform the patient of the expected success rate according to his or her own experience. In addition, the surgeon should describe and explain to the patient the secondary procedures that may be considered in the event of persistent obstruction during follow-up.

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Preprocedural Evaluation

Radiologic evaluation provides an objective assessment of the degree of obstruction. Each imaging modality provides different anatomic and functional information. Intravenous pyelography (IVP) may be performed in the initial evaluation of flank pain. Findings on IVP include marked hydronephrosis with delayed contrast excretion and a normal-caliber ureter distally.

Computed tomography (CT) provides excellent anatomic information on the kidneys and surrounding structures, the degree of hydronephrosis (see the first image below), and the presence of stones. With contrast enhancement, the presence of lower-pole crossing vessels can be accurately identified (see the second image below).[41] In the delayed excretory phase, filling defects in the renal pelvis should raise suspicion for urothelial malignancies and prompt further ureteroscopic evaluation.

CT scan showing hydronephrosis from ureteropelvic CT scan showing hydronephrosis from ureteropelvic junction obstruction.
Coronal section of CT showing lower-pole crossing Coronal section of CT showing lower-pole crossing vessels.

Functional radionuclide studies, such as mercaptoacetyltriglycine (MAG3) renal scanning, now enable noninvasive measurement of the degree of obstruction and the differential function of the affected kidney. Persistence of radionuclide in the renal pelvis despite a diuretic bolus, with prolonged (>20 minutes) elimination half-time, is diagnostic of obstruction (see the image below).

MAG3 renogram of right ureteropelvic junction obst MAG3 renogram of right ureteropelvic junction obstruction.

In equivocal situations, a Whitaker test may be necessary. This study measures the rise in intrapelvic pressure during infusion of saline through a nephrostomy catheter at a rate of 10 mL/min. An intrapelvic pressure higher than 22 cm water is indicative of obstruction.[42]

Retrograde pyelography (RPG) is useful for appreciating the anatomy and size of the renal pelvis and for determining the exact site and length of obstruction at the ureteropelvic junction (UPJ) relative to the renal pelvis (see the image below). Distal ureteral lesions can also be excluded. RPG can be performed at the same sitting as pyeloplasty, just before the procedure.

Preoperative RPG showing ureteropelvic junction ob Preoperative RPG showing ureteropelvic junction obstruction.

Occasionally, unexpected lesions (eg, polyps or small filling defects in the renal pelvis) may be demonstrated on RPG that could not be seen on CT scan (see the images below). If a suspicious urothelial lesion is seen, further ureteroscopic evaluation is warranted.

RPG demonstrating polyps at ureteropelvic junction RPG demonstrating polyps at ureteropelvic junction.
Intraoperative view of ureteropelvic junction poly Intraoperative view of ureteropelvic junction polyps causing ureteropelvic junction obstruction.

After RPG is done, a ureteral stent may be inserted up the affected ureter. An open-ended ureteric catheter is used to measure the length of the ureter from the UPJ to the ureteric orifice. The length of the stent chosen should be about 4 cm longer than the measured length of the ureter; this helps prevent the distal end from migrating into the ureter during intraoperative manipulation.

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Equipment

RLP is performed with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA). Instruments used in RLP include the following:

  • Right arm – Monopolar da Vinci Hot Shears, da Vinci Potts Scissors, da Vinci Large Needle Driver
  • Left arm – da Vinci PK (Plasma Kinetic; Gyrus ACMI, Southborough, MA) Dissecting Forceps, da Vinci Fine Tissue Forceps, da Vinci Large Needle Driver
  • Fourth arm – The authors typically do not use the fourth arm for pyeloplasty but rely on retraction sutures and stay sutures to restrict the number of trocars to 4 on the left and 5 on the right (an additional 5-mm trocar is used for retraction of the liver)
  • Assistant – Stryker Flow 2 suction irrigator (Stryker, Kalamazoo, MI)

Sutures used in RLP include the following:

  • Anastomotic suture – 4-0 or 5-0 polyglactin on RB-1 needle, cut to 5 in.
  • Retraction suture – 2-0 polyglactin
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Patient Preparation

A negative preoperative urine culture should be obtained, and any urine infection should be treated appropriately. On the day before surgery, the patient is advised to take light meals, and the bowel is cleared with a laxative. From midnight onward, the patient fasts.

Positioning

After completion of RVP during the same general anesthesia, the patient is moved so that the umbilicus is placed at the break of the table. The patient is then turned to a modified flank position at a 45° angle. The authors use an inflatable beanbag and blanket rolls placed behind the back to support the patient in this position. An axillary roll is placed just below the dependent axilla. The table is flexed slightly to increase the space over the ipsilateral flank.

The contralateral arm is placed on an arm board perpendicular to the table, and the ipsilateral arm is placed at the side of the body along the midaxillary line; placing the ipsilateral arm at the side instead of on an Allen armrest avoids collision with the upper robotic arm. The upper leg is extended, and the lower leg is flexed at the hip and knee, with a pillow placed between the legs for support. Bony prominences at the hip, knees and ankles are padded. The patient is secured to the table with tape at the chest, hips, and knees (see the image below).

Patient position before draping. Patient position before draping.

The table is rolled to either side before draping to ensure that the patient’s position is secure, especially the position of the head. Finally, the position of the table is adjusted relative to the operating room to allow the patient side cart to be brought to the patient’s upper back or shoulder (see the image below).

Patient cart position. Patient cart position.
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Monitoring and Follow-up

On postoperative day 1, the patient is allowed to resume a regular diet and is asked to ambulate. If drainage output is not excessive, the urethral catheter is removed, and the patient is allowed to void. Fluid from the bulb drain is measured for creatinine. If the creatinine level is normal, the drain is removed, and the patient can be discharged on postoperative day 1 or 2.

After 4-6 weeks, the patient returns for removal of the stent; 6-8 weeks after stent removal, a MAG3 renogram is obtained to evaluate for patency and resolution of obstruction. Further renograms are obtained 6 months and 18 months postoperatively.

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Contributor Information and Disclosures
Author

Chandru P Sundaram, MD Professor of Urology, Residency Program Director, Director of Minimally Invasive Surgery, Department of Urology, Indiana University School of Medicine

Chandru P Sundaram, MD is a member of the following medical societies: American Urological Association, Endourological Society, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Keng-Siang Png, MBBS Fellow in Minimally Invasive Surgery and Laparoscopy, Department of Urology, Indiana University School of Medicine

Disclosure: Nothing to disclose.

Clinton D Bahler, MD Fellow in Minimally Invasive Surgery, Department of Urology, Indiana University School of Medicine

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

Acknowledgements

Clinton D. Bahler, MD

Fellow in Minimally-Invasive Surgery and Laparoscopy, Department of Urology, Indiana University School of Medicine

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Robotic-assisted laparoscopic pyeloplasty: posterior transposition.
Robotic-assisted laparoscopic pyeloplasty: without transposition.
Robotic-assisted laparoscopic pyeloplasty: assessment of transposition.
Robotic-assisted laparoscopic pyeloplasty: YV plasty.
Robotic-assisted laparoscopic pyeloplasty: Fenger plasty.
Robotic-assisted laparoscopic pyeloplasty: mobilization of crossing vessels.
Robotic-assisted laparoscopic pyeloplasty: retraction sutures.
Robotic-assisted laparoscopic pyeloplasty: placement of stay sutures.
Robotic-assisted laparoscopic pyeloplasty: dismemberment and spatulation.
Robotic-assisted laparoscopic pyeloplasty: infant feeding tube.
Robotic-assisted laparoscopic pyeloplasty: anastomosis.
CT scan showing hydronephrosis from ureteropelvic junction obstruction.
Coronal section of CT showing lower-pole crossing vessels.
MAG3 renogram of right ureteropelvic junction obstruction.
Preoperative RPG showing ureteropelvic junction obstruction.
RPG demonstrating polyps at ureteropelvic junction.
Intraoperative view of ureteropelvic junction polyps causing ureteropelvic junction obstruction.
Lower-pole crossing vessels causing ureteropelvic junction obstruction.
Use of 5-French infant feeding tube and indwelling stent to assess adequacy of spatulation.
Patient position before draping.
Patient cart position.
Diagram of port placement with robotic laparoscope placed laterally.
Intraoperative view of port placement.
Table. Reported Results of Robotic-Assisted Laparoscopic Pyeloplasty
Study (N) Follow-up (mo) Success Operating Time (min) Complications Hospital Stay (days)
Erdeljan et al 2010 (88) - 93% radiographic patency; 93% pain resolution 167 5 major: migrated stent, urinoma 2.5
Etafy et al 2011 (61) 18 81% radiographic patency and pain resolution 335 4.9% clogged stent; urine leak 2
Gupta et al 2010 (85) 13.6 96.5% radiographic patency and pain resolution 121 3 urine leaks; 2 conversions; 1 port-site hernia; 1 volvulus 2.5
Mufarrij et al 2008 (140; 3 centers) 29 95.7% radiographic resolution 217 7% major (7 were stent migration); 2 urine leaks 2.1
Schwentner et al 2007 (92) 39.1 96.7% radiographic patency 108 2 urine leaks; 1 bleeding 4.6
Minnillo et al 2011 (155) 31.7 96% stable or improved hydronephrosis 198 7.7% major complications 1.9
Lucas et al 2010 (485; multiple centers) 11 96.7% radiographic patency; 95.4% symptom improvement 204 5.4% overall; 1.8% urine leak
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