Introduction
Laparoscopic pyeloplasty was first introduced in 1993 as a viable alternative to open pyeloplasty in the treatment of ureteropelvic junction (UPJ) obstruction ( ). Since then, multiple advances in technology and technique have provided excellent results comparable to the open approach with less morbidity, decreased postoperative pain, shorter hospital stay, and faster overall recovery ( ). Despite these benefits, laparoscopic pyeloplasty has a steeper learning curve than the open approach, because of technically challenging intracorporeal suturing. Robot-assisted pyeloplasty was initially described in 2001 and provides the benefits of the laparoscopic approach with an easier technique to perform the delicate suturing required for the anastomosis due to wrist mobility ( ). In this chapter, we discuss the preoperative preparation, surgical technique, and postoperative considerations for laparoscopic and robotic pyeloplasty. Because the technique is similar for both the laparoscopic and robotic approach, we will concentrate on the key differences in preparation and trocar placement.
Preoperative Evaluation and Preparation
The indications for laparoscopic/robotic pyeloplasty are the same as for open pyeloplasty. Patients with ipsilateral flank pain, deterioration of renal function, stones, and/or infections should be considered for pyeloplasty. The goal of intervention is to provide resolution to clinical symptoms and conserve renal function.
The patient should be evaluated with a complete history, physical examination, and laboratory work including urinalysis. Dietl crisis occurs with intermittent UPJ obstruction and is often associated with a renal lower pole vessel. The patient may complain of episodic crampy flank pain, nausea, and vomiting following fluid intake. Also, imaging with spiral CT is helpful to evaluate anatomy and exclude stones, aberrant or crossing vessels, duplicated systems, ureteral dilation, or other anatomic variants, including horseshoe kidneys. We obtain a nuclear imaging MAG3 renal scan with Lasix washout to determine split renal function and quantify the degree of UPJ obstruction. If the referred patient presents with an indwelling ureteral stent, it is our practice to remove the stent at least 2 weeks before surgery to minimize periureteral inflammation and facilitate dissection.
Contraindications are similar to any laparoscopic procedure and include uncorrectable coagulopathy, active infection, and severe cardiopulmonary disease, which will not tolerate pneumoperitoneum. The patients receive a bowel preparation the day before surgery with 20 mL of magnesium citrate and a Fleets enema.
Preoperative Evaluation and Preparation
The indications for laparoscopic/robotic pyeloplasty are the same as for open pyeloplasty. Patients with ipsilateral flank pain, deterioration of renal function, stones, and/or infections should be considered for pyeloplasty. The goal of intervention is to provide resolution to clinical symptoms and conserve renal function.
The patient should be evaluated with a complete history, physical examination, and laboratory work including urinalysis. Dietl crisis occurs with intermittent UPJ obstruction and is often associated with a renal lower pole vessel. The patient may complain of episodic crampy flank pain, nausea, and vomiting following fluid intake. Also, imaging with spiral CT is helpful to evaluate anatomy and exclude stones, aberrant or crossing vessels, duplicated systems, ureteral dilation, or other anatomic variants, including horseshoe kidneys. We obtain a nuclear imaging MAG3 renal scan with Lasix washout to determine split renal function and quantify the degree of UPJ obstruction. If the referred patient presents with an indwelling ureteral stent, it is our practice to remove the stent at least 2 weeks before surgery to minimize periureteral inflammation and facilitate dissection.
Contraindications are similar to any laparoscopic procedure and include uncorrectable coagulopathy, active infection, and severe cardiopulmonary disease, which will not tolerate pneumoperitoneum. The patients receive a bowel preparation the day before surgery with 20 mL of magnesium citrate and a Fleets enema.
Surgical Approach
There are two approaches to laparoscopic/robotic pyeloplasty including the transperitoneal and robotic approach. The transperitoneal approach is widely accepted and more advantageous for beginners because there is a large working space for reconstructive surgery. There is an increased risk for postoperative ileus and bowel injury, when compared with the retroperitoneal approach, which avoids the peritoneum. The retroperitoneal approach has been used because it allows faster access to retroperitoneal structures with less dissection, but there is a steeper learning curve as a result of the considerably smaller working space. At our institution, we perform most pyeloplasties via a transperitoneal approach because it allows adequate working space to perform the reconstruction of the UPJ.
Surgical Technique
A traditional Anderson-Hynes dismembered pyeloplasty is our technique of choice because it allows reconstruction of a large renal pelvis, treatment of high ureteral insertions, and transposition for lower pole crossing vessels. Other non-dismembered techniques including the Fenger pyeloplasty and Foley Y-V have been successfully performed in patients with a short narrowing of the UPJ. In this chapter, we present a step-by-step approach to transperitoneal dismembered pyeloplasty.
Transperitoneal Dismembered Pyeloplasty
Operating Room, Positioning, and Access
The patient is initially placed in supine position for induction of anesthesia. Antibiotic prophylaxis with a single preoperative intravenous dose with a second-generation cephalosporin is given, unless allergic to penicillin. Sequential compression stocking are used for deep vein thrombosis (DVT) prophylaxis. An orogastric tube is highly recommended for gastric decompression prior to access. We then place the patient in lithotomy position and perform a retrograde pyelogram to rule out a distal ureteral obstruction. In female patients, we generally place a ureteral stent and a Foley catheter at this time. It is our preference in males to place the ureteral stent antegrade at the time of pyeloplasty and verify its position by performing flexible cystoscopy.
Positioning for transperitoneal laparoscopic and robotic pyeloplasty is essentially identical. The patient is then placed in 70-degree lateral decubitus position with the umbilicus at the break of the table ( Fig. 22.1 ). The table is partially flexed and the patient is held in position with a beanbag and tape. All pressure points are padded and arms are secured in anatomic position away from the surgical area. We do not typically use an axillary roll, because we can provide adequate axillary support with the beanbag. The patient is then prepped, draped, and in males a Foley catheter is placed at this time.
After sterile preparation and draping, a 12-mm incision is made about 2 fingerbreadths lateral to the umbilicus. The dermis and subcutaneous tissues area dissected with electrocautery, the rectus fascia is identified and lifted, and a Verres needle is used to establish a pneumoperitoneum of 10–15 mm Hg. Following insufflation, a Versaport Bladeless 12-mm trocar (Covidien, Dublin, Ireland) is inserted blindly. An alternative open Hassan technique can be performed and a balloon trocar can be used if there is history of prior abdominal surgery. The camera is then inserted and the abdomen inspected for access-related injuries or bowel adhesions.
For a standard laparoscopic pyeloplasty, a 10-mm, 30-degree lens is used to guide entry of the accessory trocars. The triangulation rule is followed to place two additional accessory trocars at least four fingerbreadths from the primary trocar. A 12-mm trocar is placed cranial and a 5-mm trocar is placed caudal and lateral at least four fingerbreadths away from the initial periumbilical trocar following the triangulation rule ( Fig. 22.2 ). An optional 5-mm assistant trocar can be placed four fingerbreadths caudal to the primary periumbilical trocar. The most cranial trocar is used for the camera, while using the other periumbilical and lower abdominal trocars to place working instruments. During the pyeloplasty, we use the Ligasure device (Covidien, Dublin, Ireland), smooth monopolar scissors, blunt graspers, a suction device, and needle drivers.
Trocar placement for robotic pyeloplasty is similar to the laparoscopic approach. Two 8-mm robotic working trocars are placed using the triangulation rule, cranially and caudal and lateral, toward the ASIS. These ports are placed 10 cm from the optical periumbilical trocar, to avoid robotic collisions. An additional assistant 12-mm trocar is placed caudal to the optical trocar ( Fig. 22.3 ). The assistant can use this trocar to provide suction, retraction, and bring in sutures. In obese patients, trocar are moved slightly cranial and laterally. The robot is docked over the patient’s shoulder, which provides a direct view of the UPJ and adequate working space for instruments ( Fig. 22.4 ). It is our preference to use the 30-degree down robotic camera, robotic monopolar scissors on the right robotic arm, and robotic ProGrasp on the left robotic arm.
Surgical Steps
Mobilization of Colon and Exposure of UPJ ( Fig. 22.5 ).
The plane between the mesocolic fat and underlying Gerota fascia is dissected, allowing the colon to fall medially. In the left side, the spleno-colic attachment may need to be divided to allow exposure to the UPJ. For a right-sided pyeloplasty, the duodenum may need to be kocherized with cold scissors and mobilized medially.
Dissection of Proximal Ureter, UPJ, and Renal Pelvis ( Fig. 22.6 ).
Following exposure of Gerota fascia, an incision is made on its medial border, close to the lower pole of the kidney. Identification of the gonadal vein can help identification of the ureter as it crosses the ureter near the lower pole. The ureter is mobilized to the renal pelvis with care not to disturb its adventitial blood supply. Anterior retraction of the ureter can help with identification of the UPJ. The perirenal fat is carefully dissected off the UPJ and renal pelvis with consideration for possible lower pole crossing vessels. The narrowed UPJ can be grasped to aid with dissection of the renal pelvis. Alternatively, placement of a stay or “hitch” stitch passed to the renal pelvis and sutured to the abdominal wall or out through the abdominal wall provides adequate retraction of the renal pelvis.
Transection of UPJ, Spatulation of the Ureter, and Treatment of Stones ( Fig. 22.7 ).
Once the renal pelvis is fully mobilized, the UPJ is transected above the narrowed segment from superolateral to inferomedially. The obstructed segment and renal pelvis flap is left on the ureter to aid as a handle during spatulation and anastomosis. In cases were a ureteral stent was preplaced, care is taken not to transect the stent during UPJ excision. The ureter is spatulated with monopolar scissors laterally for 1.5–2 cm. Potts scissors are sometimes required for small ureteral lumens. It is important to remain oriented and continue the spatulation laterally and not spiral the ureter, which will decrease the caliber and diameter of the lumen following the anastomosis. A stay stitch can be placed medially before transection to maintain orientation of the ureter and avoid twisting/spiraling.
If the renal pelvis is large and dilated, the redundant pelvis may be excised this time, with care not to expose the renal calices, which can promote scarring and narrowing of the UPJ. If renal calculi are present in the renal pelvis, they can be removed with the robotic instruments if visible. If stone extraction for caliceal stones is anticipated, a small incision is made in the renal pelvis prior to excision of the UPJ to allow passage of a flexible cystoscope and permit adequate flow of irrigation fluid. The stones can then be extracted with a basket and placed in an Endocatch bag.
Anastomosis and Ureteral Stent Placement ( Figs. 22.8 through 22.12 ).
The posterior anastomosis is started at the inferior apex of the spatulated ureter, which sutured to the most inferior aspect of the renal pelvis. The 4.0 monocryl is then tied aligning the ureter and pelvis without tension. The needle is then passed under the ureter to perform the running posterior anastomosis. Following completion of the posterior anastomosis antegrade stenting is performed in males. A guidewire is brought in through the assistant port and advanced toward the lumen of the proximal ureter and down to the bladder. A double-J ureteral stent is then advanced in antegrade fashion into the bladder, the wire is removed, and the proximal J is inserted into the renal pelvis. Proper distal placement of the stent is confirmed with flexible cystoscopy. The renal pelvis/UPJ flap is excised from the proximal ureter and the anterior anastomosis is the completed using a new 4.0 absorbable monofilament suture using a running technique.
