We do not routinely utilize a bowel preparation for our patients undergoing pyeloplasty. A clear liquid diet the day prior to surgery is advised. Important consideration for the patient to be aware of is that the goal of the surgery is to improve the drainage of the affected kidney to preserve/improve renal function as well as avoid renal colic . It may be required in some instances to convert to an open operation. Blood transfusions, devascularization of the lower pole of the kidney, bowel injury, and prolonged urine leaks are extremely rare events. The informed consent should focus primarily on possible stenosis or obstruction after the surgery has been completed but may include comments outlined above.

At our institution we currently utilize the da Vinci^® Xi Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA). The steps described in this chapter were originally developed for the “standard” DaVinci robot, and were modified over the past decade as “DaVinci S’ and “Si” models were introduced. Although four robotic arms are available, robotic pyeloplasty is generally and preferably performed using a three-armed technique by the authors. Only one surgical assistant is required in addition to a scrub technician, both of whom stand on the abdominal side of the patient. All accessory instrument exchanges, suction, needle passages are performed by the bedside assistant utilizing the 8 mm robotic trocar thus eliminating the need for a designated “assistant trocar”. Since the point of attack is typically at the lower third of the renal operative field, a “retractor” placed via the assistant trocar is rarely required, even on the right side where the liver can sometimes be overhanging. If, however, the surgeon and patient will benefit from the placement of a fourth and fifth trocar, one should not hesitate to place them in the appropriate locations. The vision cart is positioned so that it is easily seen by both the assistant and scrub technician. The patient-side robotic cart is positioned over the patient’s ipsilateral shoulder for the “S” and “Si” models , and directly parallel to the spine when utilizing the “Xi”. The final operating room setup is as shown in Fig. 11.2.

Our technique with robotic pyeloplasty has been previously described and has been modified slightly over the years [6]. After cystoscopy and retrograde pyelography with ureteral stent placement in the lithotomy position (see below) the patient is moved to the operating table. This can be accomplished in the same room with the addition of C-Arm fluoroscopy . Conversely, this can be done in a standard cystoscopy suite with transfer via gurney to a robotic suite and placed in a supine position on the operating table. Pneumatic compression stockings, urethral catheter, and an orogastric tube are routinely employed. Next, patients are positioned in a modified flank position with a 30° tilt and are held in place with a conformable vacuum “Bean-Bag” (Olympia, Seattle, Washington). It is not generally necessary to “flex the table” to increase space. A sub-axillary roll (gel or 1 L IV bag wrapped in a towel) is employed to prevent brachial plexus injury. The ipsilateral (“up”) arm is supported in an Amsco “Krause” arm support that is placed above the chest to allow the arms of the robot sufficient space to maneuver [S; Si]. Alternatively when utilizing the Xi, the ipsilateral arm can be secured along side the patient in a “Marching Soldier” position. The contralateral (“down”) arm must lie low and angled slightly cephalad enough to allow for the midline robotic trocar and working element to be positioned without interference (Fig. 11.3a, b). The patient is secured at the arms, chest, hips, and legs with crosstable 3 in. silk tape and Velcro straps (Fig. 11.3b). Finally, the bed is rotated on its central axis both clockwise and counterclockwise prior to draping to ensure that the patient is adequately secured to the table.

For the majority of patients, a 12 mm camera trocar is placed at the inferior crease of the umbilicus (Fig. 11.4). This allows for wide field of view and is cosmetically appealing. For those with obese or redundant abdominal wall, the initial trocars can be moved laterally at the edge of the rectus muscle. Insertion of the secondary trocars is performed only after careful inspection of the abdomen for the presence of adhesions. One of the 8 mm working arm trocars is placed 8–10 cm superior to the camera trocar in the midline and the second is placed 8–10 cm lateral with a 10° inferior angle from the umbilicus (Fig. 11.5a). A 5 mm assistant trocar can be placed midway and slightly lower than the umbilical and subxyphoid 8 mm robotic trocar. The final trocar configuration for a three armed robotic technique is as shown in Fig. 11.5a. When using the fourth robotic arm, an additional 8 mm robotic trocar is inserted low in the ipsilateral iliac fossa.

It should be noted that with the Da Vinci Xi system the patient is placed in the “Marching Soldier” position with the ipsilateral arm flexed at the patient’s side and the contralateral arm outstretched across an operating table arm board with the operating table flat or slightly flexed as shown in Fig. 11.3b. Trocars can then be placed in a linear fashion as instrumental interference is much less common with the Xi due to improved ergonomics. Conversely, triangulation can be used to try to optimize cosmesis (surgeon preference).