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Robotic-Assisted Laparoscopic Pyeloplasty Technique

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

Laparoscopic Pyeloplasty With Robotic Assistance

Port placement

With the patient rotated to almost a supine position, pneumoperitoneum is created via a Veress needle placed at the umbilicus. After insufflation to a pressure of 15 mm Hg, a 12-mm bladeless trocar is inserted at the umbilicus. A regular 10-mm laparoscope is inserted, and the abdominal cavity is inspected for injury and adhesions. On the right side, a 5-mm subxiphisternal port is inserted to allow retraction of the liver[link “liver” to Medscape topic Liver Anatomy].

The table is now rolled toward the surgeon so that the patient is at a 90° angle relative to horizontal. Additional trocars are placed according to 1 of the following 3 configurations:

  • Lateral laparoscope position
  • Modified paramedian position
  • Medial position

Lateral laparoscope position

The lateral laparoscope position (also referred to as the diamond pattern) is used for robotic-assisted laparoscopic pyeloplasty (RLP) in pediatric patients and smaller adults. A 12-mm port for the robotic camera is situated 2 cm medial and inferior to the tip of the 12th rib, approximately along the anterior axillary line. At this position, the robotic camera is placed with the lens facing upward at a 30° angle.

Next, a pair of 8-mm robotic trocars are placed. The first is placed 2 cm inferior to the costal margin, just medial to the midclavicular line, and the other is placed 2 fingerbreadths superior to the iliac crest, just lateral to the midclavicular line. If the fourth robotic arm is used, the third 8-mm trocar can be placed medial and inferior to the lower robotic port, almost at the suprapubic region (see the images below). After the patient cart is docked, the 12-mm umbilical port is used for the assistant’s instruments.

Diagram of port placement with robotic laparoscope Diagram of port placement with robotic laparoscope placed laterally.
Intraoperative view of port placement. Intraoperative view of port placement.

Modified paramedian position

In most adults, the laparoscope can be moved medially toward the lateral border of the rectus abdominis or the midclavicular line about 3 cm above the level of the umbilicus. The 8-mm trocar for the right-hand robotic instrument is inserted in the subcostal location in line with the laparoscope. The 8-mm trocar for the left-hand robotic instrument is inserted between the umbilicus and the anterior superior iliac spine.

Medial position

The robotic camera can also be placed through the umbilical port. When the camera is inserted in this medially located position, it should be oriented so that the lens faces downward at a 30° angle.

Mobilization of ureteropelvic junction

The first step in exposing the ureteropelvic junction (UPJ) is to reflect the colon[link “colon” to Medscape topic Colon Anatomy] by incising the line of Toldt. The plane between the colon and mesocolon and Gerota’s fascia is developed as the colon is reflected medially. In thin patients with minimal mesenteric fat, left-side exposure can be achieved via the transmesocolic approach.[43]

The next landmark is the gonadal vein, which can be identified at the level of the lower pole of the kidney after adequate medial mobilization of the colon. Posterior to the gonadal vein, the psoas fascia can be seen. In this region, the ureter can usually be identified. At this point, the Foley catheter is clamped to allow urine to flow back up the stent and distend the renal pelvis.

The ureter is freed proximally until the renal pelvis is exposed. During this step, it is important to watch for crossing vessels, which, if present, should be dissected off the UPJ (see the video below). The periureteral tissue should be preserved during dissection to avoid the complication of late ischemic stricture.

Robotic-assisted laparoscopic pyeloplasty: mobilization of crossing vessels.

The perirenal fat around the pelvis and retroperitoneal fat around the proximal ureter may make exposure difficult. Retraction sutures can be used to facilitate exposure of the UPJ without the use of another trocar or instrument. These may be sutured to surrounding fascia laterally to facilitate the rest of the surgery (see the video below).

Robotic-assisted laparoscopic pyeloplasty: retraction sutures.

In addition, the authors routinely place stay sutures on the renal pelvis and proximal ureter to facilitate handling of the tissues during dismembering of the UPJ (see the video below).

Robotic-assisted laparoscopic pyeloplasty: placement of stay sutures.

With the renal pelvis distended, the narrowed segment of the UPJ is identified. The cephalad robotic instrument is changed to Potts scissors. While the tissues are being handling with the stay sutures, the medial edge of the renal pelvis is incised 2 cm above the narrowed segment. The incision is carried along the anterior wall of the pelvis, extending inferolaterally until the lateral edge of the UPJ is reached.

The angle of the scissors is then turned inferiorly to spatulate the lateral wall of the ureter for about 1-3 cm, depending on the redundancy of the pelvis and ureter and the degree of tension. Dismemberment is completed by dividing the posterior wall of the renal pelvis parallel to the anterior wall. Spatulation of the ureter before dismemberment helps maintain the correct orientation of the ureter during spatulation. The UPJ remains attached to the ureter, serving as a handle for manipulation during anastomosis (see the video below).

Robotic-assisted laparoscopic pyeloplasty: dismemberment and spatulation.


Once the UPJ is dismembered, the next step is to make an assessment of the obstructive nature of any crossing vessels present. If necessary, the vessels may be transposed posteriorly. The ureter and the pelvis are then brought together for assessment of the degree of tension. Additional ureteral mobilization may be performed at this stage if necessary. Redundant pelvis may also be excised to achieve a funnel-shaped anastomosis.

The anastomosis is created with 4-0 or 5-0 polyglactin suture on an RB-1 needle. On the left side, starting with the ureter, the needle is passed from out to in at the apex of the spatulation. The suture is then passed from in to out at the lateral edge of the pelvis, and the knot is tied. On the right side, suturing is begun at the lateral edge of the renal pelvis from out to in, then continued from in to out through the ureteral spatulation.

In both cases, the posterior wall is first performed with a continuous stitch and ended medially with the needle on the outside. Interrupted sutures may also be used, especially for the posterior layer. Sutures should be carefully handled to ensure that they are not weakened or frayed.

After the posterior wall is completed, a final assessment of the patency of the anastomosis is made by using a 5-French infant feeding tube inserted alongside the stent into the ureter (see the video below). The renal pelvis is irrigated copiously to flush out any clot that might cause transient stent obstruction postoperatively.

Robotic-assisted laparoscopic pyeloplasty: infant feeding tube.

The proximal coil of the stent is replaced into the renal pelvis, and the anterior wall of the anastomosis is begun. A new suture is used for the anterior wall, starting laterally in a similar fashion and continued medially. The anterior suture is tied to the free end of the posterior suture to complete the anastomosis (see the video below).

Robotic-assisted laparoscopic pyeloplasty: anastomosis.

After the anastomosis has been completed and hemostasis ensured, all stay sutures are removed. The instruments are removed, and the arms are undocked from the ports. A 10-French or 15-French round drain is placed through one of the 8-mm ports and connected to bulb suction. The fascial openings at the 12-mm port sites are closed. In children, the fascial openings at all trocar sites are closed.




Intraoperative complications during RLP are rare, with frequencies ranging from 0-2%.[34, 35] Such complications include elective conversions, splenic and liver lacerations caused during instrument exchange, and minor bowel injuries. Major vascular injuries are extremely rare.


Urine leakage occurs during the early postoperative period in 2% of cases.[36] This is manifested as increased drainage output with a fluid creatinine concentration consistent with that of urine. It can be caused by transient obstruction by blood clot, a kinked stent, migration of the distal end of the stent up the ureter, or a disrupted anastomosis.

Abdominal radiography should be performed to confirm the position of the stent. A migrated or kinked stent should be adjusted ureteroscopically. Percutaneous nephrostomy may aid in additional drainage if necessary. A disrupted anastomosis is best treated by means of surgical revision. Intravenous antibiotic therapy should be instituted and computed tomography ordered with a view to draining any abscess or collection.


Persistent obstruction during follow-up renograms occurs in fewer than 10% of cases.[37] Treatment of persistent obstruction will depend on the surgeon’s experience and the patient’s preference. Both endopyelotomy and repeat pyeloplasty have been used in cases of secondary UPJO, with reported success rates exceeding 80%.[15, 44]

Contributor Information and Disclosures

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.


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.


Clinton D. Bahler, MD

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

  1. Scardino PT, Scardino PL. Obstruction at the ureteropelvic junction. H B, editor. The ureter. 2nd ed. New York: Springer Verlag; 1981. 697.

  2. Burgess NA, Koo BC, Calvert RC, Hindmarsh A, Donaldson PJ, Rhodes M. Randomized trial of laparoscopic v open nephrectomy. J Endourol. 2007 Jun. 21(6):610-3. [Medline].

  3. Badlani G, Eshghi M, Smith AD. Percutaneous surgery for ureteropelvic junction obstruction (endopyelotomy): technique and early results. J Urol. 1986 Jan. 135(1):26-8. [Medline].

  4. Motola JA, Badlani GH, Smith AD. Results of 212 consecutive endopyelotomies: an 8-year followup. J Urol. 1993 Mar. 149(3):453-6. [Medline].

  5. Gerber GS, Kim JC. Ureteroscopic endopyelotomy in the treatment of patients with ureteropelvic junction obstruction. Urology. 2000 Feb. 55(2):198-202; discussion 202-3. [Medline].

  6. Conlin MJ, Bagley DH. Ureteroscopic endopyelotomy at a single setting. J Urol. 1998 Mar. 159(3):727-31. [Medline].

  7. Shalhav AL, Giusti G, Elbahnasy AM, Hoenig DM, McDougall EM, Smith DS. Adult endopyelotomy: impact of etiology and antegrade versus retrograde approach on outcome. J Urol. 1998 Sep. 160(3 Pt 1):685-9. [Medline].

  8. Kavoussi LR, Peters CA. Laparoscopic pyeloplasty. J Urol. 1993 Dec. 150(6):1891-4. [Medline].

  9. Schuessler WW, Grune MT, Tecuanhuey LV, Preminger GM. Laparoscopic dismembered pyeloplasty. J Urol. 1993 Dec. 150(6):1795-9. [Medline].

  10. Bauer JJ, Bishoff JT, Moore RG, Chen RN, Iverson AJ, Kavoussi LR. Laparoscopic versus open pyeloplasty: assessment of objective and subjective outcome. J Urol. 1999 Sep. 162(3 Pt 1):692-5. [Medline].

  11. Eden CG, Cahill D, Allen JD. Laparoscopic dismembered pyeloplasty: 50 consecutive cases. BJU Int. 2001 Oct. 88(6):526-31. [Medline].

  12. Klingler HC, Remzi M, Janetschek G, Kratzik C, Marberger MJ. Comparison of open versus laparoscopic pyeloplasty techniques in treatment of uretero-pelvic junction obstruction. Eur Urol. 2003 Sep. 44(3):340-5. [Medline].

  13. Janetschek G, Peschel R, Bartsch G. Laparoscopic Fenger plasty. J Endourol. 2000 Dec. 14(10):889-93. [Medline].

  14. Turk IA, Davis JW, Winkelmann B, Deger S, Richter F, Fabrizio MD. Laparoscopic dismembered pyeloplasty--the method of choice in the presence of an enlarged renal pelvis and crossing vessels. Eur Urol. 2002 Sep. 42(3):268-75. [Medline].

  15. Sundaram CP, Grubb RL 3rd, Rehman J, Yan Y, Chen C, Landman J. Laparoscopic pyeloplasty for secondary ureteropelvic junction obstruction. J Urol. 2003 Jun. 169(6):2037-40. [Medline].

  16. Brooks JD, Kavoussi LR, Preminger GM, Schuessler WW, Moore RG. Comparison of open and endourologic approaches to the obstructed ureteropelvic junction. Urology. 1995 Dec. 46(6):791-5. [Medline].

  17. Yong D, Albala DM. Endopyelotomy in the age of laparoscopic and robotic-assisted pyeloplasty. Curr Urol Rep. 2010 Mar. 11(2):74-9. [Medline].

  18. Gallo F, Schenone M, Giberti C. Ureteropelvic junction obstruction: which is the best treatment today?. J Laparoendosc Adv Surg Tech A. 2009 Oct. 19(5):657-62. [Medline].

  19. Monn MF, Bahler CD, Schneider EB, Sundaram CP. Emerging trends in robotic pyeloplasty for the management of ureteropelvic junction obstruction in adults. J Urol. 2013 Apr. 189(4):1352-7. [Medline].

  20. Hsu TH, Streem SB, Nakada SY. Management of upper urinary tract obstruction. Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walsh Urology. 9th ed. Philadelphia: Saunders Elsevier; 2007.

  21. Grasso M, Caruso RP, Phillips CK. UPJ Obstruction in the Adult Population: Are Crossing Vessels Significant?. Rev Urol. 2001. 3(1):42-51. [Medline].

  22. Van Cangh PJ, Nesa S. Endopyelotomy. Prognostic factors and patient selection. Urol Clin North Am. 1998 May. 25(2):281-8. [Medline].

  23. Boylu U, Oommen M, Lee BR, Thomas R. Ureteropelvic junction obstruction secondary to crossing vessels-to transpose or not? The robotic experience. J Urol. 2009 Apr. 181(4):1751-5. [Medline].

  24. Canes D, Desai MM, Haber GP, Colombo JR, Turna B, Kaouk JH. Is routine transposition of anterior crossing vessels during laparoscopic dismembered pyeloplasty necessary?. J Endourol. 2009 Mar. 23(3):469-73. [Medline].

  25. Wayment RO, Waller CJ, Kramer BA, Schwartz BF. Intraoperative cystoscopic stent placement in robot-assisted pyeloplasty: a novel and efficient technique. J Endourol. 2009 Apr. 23(4):583-6; discussion 586-7. [Medline].

  26. Peschel R, Neururer R, Bartsch G, Gettman MT. Robotic pyeloplasty: technique and results. Urol Clin North Am. 2004 Nov. 31(4):737-41. [Medline].

  27. Mendez-Torres F, Woods M, Thomas R. Technical modifications for robot-assisted laparoscopic pyeloplasty. J Endourol. 2005 Apr. 19(3):393-6. [Medline].

  28. Sethi AS, Regan SM, Sundaram CP. Robot-assisted laparoscopic pyeloplasty with and without a ureteral stent. J Endourol. 2011 Feb. 25(2):239-43. [Medline].

  29. Bird VG, Leveillee RJ, Eldefrawy A, Bracho J, Aziz MS. Comparison of robot-assisted versus conventional laparoscopic transperitoneal pyeloplasty for patients with ureteropelvic junction obstruction: a single-center study. Urology. 2011 Mar. 77(3):730-4. [Medline].

  30. Bernie JE, Venkatesh R, Brown J, Gardner TA, Sundaram CP. Comparison of laparoscopic pyeloplasty with and without robotic assistance. JSLS. 2005 Jul-Sep. 9(3):258-61. [Medline].

  31. Braga LH, Pace K, DeMaria J, Lorenzo AJ. Systematic review and meta-analysis of robotic-assisted versus conventional laparoscopic pyeloplasty for patients with ureteropelvic junction obstruction: effect on operative time, length of hospital stay, postoperative complications, and success rate. Eur Urol. 2009 Nov. 56(5):848-57. [Medline].

  32. Silay MS, Spinoit AF, Undre S, et al. Global minimally invasive pyeloplasty study in children: Results from the Pediatric Urology Expert Group of the European Association of Urology Young Academic Urologists working party. J Pediatr Urol. 2016 May 12. [Medline].

  33. Fontenot PA Jr, Capoccia TR, Wilson B, Arthur A, Duchene DA. Robotic-assisted Laparoscopic Pyeloplasty: Analysis of Symptomatic Patients With Equivocal Renal Scans. Urology. 2016 Jul. 93:92-6. [Medline].

  34. Mufarrij PW, Woods M, Shah OD, Palese MA, Berger AD, Thomas R, et al. Robotic dismembered pyeloplasty: a 6-year, multi-institutional experience. J Urol. 2008 Oct. 180(4):1391-6. [Medline].

  35. Schwentner C, Pelzer A, Neururer R, Springer B, Horninger W, Bartsch G. Robotic Anderson-Hynes pyeloplasty: 5-year experience of one centre. BJU Int. 2007 Oct. 100(4):880-5. [Medline].

  36. Lucas SM, Sundaram CP, Leveillee RJ, Bird VG. Laparoscopic and robotic pyeloplasty collaborative group: Analysis of factors influencing success in 800 patients. J Endourol. 2010. 24(S1):A31-A2.

  37. Gupta NP, Nayyar R, Hemal AK, Mukherjee S, Kumar R, Dogra PN. Outcome analysis of robotic pyeloplasty: a large single-centre experience. BJU Int. 2010 Apr. 105(7):980-3. [Medline].

  38. Erdeljan P, Caumartin Y, Warren J, Nguan C, Nott L, Luke PP. Robot-assisted pyeloplasty: follow-up of first Canadian experience with comparison of outcomes between experienced and trainee surgeons. J Endourol. 2010 Sep. 24(9):1447-50. [Medline].

  39. Etafy M, Pick D, Said S, Hsueh T, Kerbl D, Mucksavage P. Robotic pyeloplasty: the University of California-Irvine experience. J Urol. 2011 Jun. 185(6):2196-200. [Medline].

  40. Minnillo BJ, Cruz JA, Sayao RH, et al. Long-term experience and outcomes of robotic assisted laparoscopic pyeloplasty in children and young adults. J Urol. 2011 Apr. 185(4):1455-60. [Medline].

  41. Rabah DM, Al-Hathal N, Al-Fuhaid T, Raza S, Al-Yami F, Al-Taweel W. Computed tomography angiogram: accuracy in renal surgery. Int J Urol. 2009 Jan. 16(1):58-60. [Medline].

  42. Whitaker RH. Methods of assessing obstruction in dilated ureters. Br J Urol. 1973 Feb. 45(1):15-22. [Medline].

  43. Gupta NP, Mukherjee S, Nayyar R, Hemal AK, Kumar R. Transmesocolic robot-assisted pyeloplasty: single center experience. J Endourol. 2009 Jun. 23(6):945-8. [Medline].

  44. Patel T, Kellner CP, Katsumi H, Gupta M. Efficacy of endopyelotomy in patients with secondary ureteropelvic junction obstruction. J Endourol. 2011 Apr. 25(4):587-91. [Medline].

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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