We have performed robotic ureterolysis with omental wrap in patients with ureteral obstruction secondary to retroperitoneal fibrosis. This procedure can be done unilaterally or bilaterally as dictated based on the patient’s clinical scenario.

As most of our ureterolyses have involved the mid to upper ureter, we usually place the patient in a lateral or semi-lateral decubitus position. The patient’s anterior superior iliac spine is placed directly over the flexion pivot of the operating table to allow for maximal patient flexion when desired. Two gel rolls are placed behind the patient, one at the upper back and the other at the lower back and buttocks, to help maintain a 45–60° angle. An axillary roll is placed under the patient’s axilla to prevent brachial plexus injuries, and a rolled-up foam pad can be placed between the upper shoulder and neck for support. The patient’s lower arm is placed on an arm board, and foam pads are stacked on top of it to create a place for the patient’s upper arm to rest comfortably. To improve access for the superior robotic trocar, instead of placing the upper arm across the body, the upper arm may be placed on the side of the body. The arm is placed on a neutral position, and a tape sling is placed under the elbow for support. The lower leg is flexed at the hip and knee while the upper leg is positioned straight; a pillow is placed in between the legs, and sequential compression boots are also employed for deep venous thrombosis prophylaxis. The patient is secured to the table with 3-in. silk or cloth tape. Attention is paid to ensure that all pressure points are padded. Once docked, the table is maximally rotated to allow gravitational mobilization of the bowel.

Alternatively, a lateral decubitus position with the patient in a modified low-lithotomy can be employed, as described by Wong and Leveillee [1]. In this case, the patient’s legs would be placed in low-lithotomy for access to the urethra in female patients. In male patients, for access to the urethra, the patient’s penis is prepped into the field. It is very important that the legs are positioned so that the majority of the weight is supported by the feet and that adequate padding is used to prevent nerve compression. The advantage of this position is easier access to the bladder and ureter that does not require undocking the robot or changing patient position. The disadvantage is not being able to maximally flex the table to obtain increased working space along the ipsilateral flank.

In cases where bilateral ureteral surgery, we typically undock the robot, cover or close all trocar sites, move the robot to the contralateral side and reposition the patient with the contralateral side facing up. Our average repositioning time has been 20 min.

In patients who require ureterolysis of the distal ureter below the iliac vessels, requiring a ureteral reimplantation, it may be necessary to place the patient in a low-lithotomy position with steep Trendelenburg, similar to a robotic prostatectomy position . If using the modified flank low-lithotomy position, the table can be airplaned flat and robot moved inferior to the legs so it is in position for access to the bladder.

We prefer to utilize four arms and one assistant trocar . For the Si robot, a 12 mm camera trocar is placed directly above the umbilicus and two 8 mm trocars are positioned 2–4 cm lateral and 8–10 cm away from the origin in either direction. These three trocars create a “V” shaped configuration (Fig. 13.6a). The fourth arm is in the lower quadrant 2 cm above pubic bone in the midclavicular line, and the assistant trocar is just below the umbilicus (Fig. 13.6b). We currently use an 8 mm AirSeal^® Access Port (SurgiQuest, Milford, CT) which provides stable pneumoperitoneum as the assistant port. If AirSeal^® is not available, a 5 mm trocar may be used instead. The robot is docked perpendicular to table. In terms of access, we use the Hasson technique and the Applied gel trocar (Applied Surgical, LLC, Birmingham, AL). For obese patients, this template is shifted laterally to ensure there is adequate access to the diseased ureter.

When cystoscopy , retrograde pyelography, and placement of an indwelling ureteral stent are initially performed we utilize the modified flank low-lithotomy position. Retrograde pyelography allows confirmation of the level and length of the compressed ureter, while placing the stent is mandatory in the event of inadvertent ureteral injury and may be helpful identifying the ureter with intraoperative ultrasonography in cases of severe fibrosis and inflammation.

Trocar configuration is described in detail above. Prior to docking, the table is maximally rotated to full flank to allow gravitational mobilization of the intestines. The robot is then brought in perpendicular to the operating table.

Exposure of the entire ureter is paramount , and this is accomplished on the left by medializing the colon to the aorta from the spleen to the bladder, and, on the right, by medializing the colon and duodenum to the vena cava from the liver to the bladder (Fig. 13.7). Having the table rotated so that the patient is full flank helps with this exposure. The console surgeon utilizes the Gyrus PK bipolar graspers (ACMI/Olympus, Southborough, MA) in the left hand and the curved robotic scissors in the right, while the side surgeon assists with a suction-irrigator. Electrocautery settings include 50 W coagulation for the monopolar curved scissors, 50 W for Maryland bipolar graspers, and VP3-40 setting for the Gyrus PK bipolar graspers. Once the entire retroperitoneum is exposed landmarks such as the gonadal vessels, iliac vessels, and lower pole of the kidney become instrumental in identifying and locating the ureter. In some cases, intraoperative laparoscopic Doppler ultrasonography can help to identify the ureter (via imaging the course of the indwelling ureteral stent) and vascular structures , which may be obscured by the dense surrounding fibrosis.

Once the ureter is identified, the healthy distal and proximal portions of the ureter are isolated with Vessiloops (Getz Bros, Chicago, IL), which are shortened and secured with a Hem-o-lok^® clip (Fig. 13.8). To rule out the presence of lymphoma or other retroperitoneal malignancy, a frozen section of the retroperitoneal tissue is routinely sent prior to proceeding with the ureterolysis . The diseased, entrapped ureteral segment is dissected free by splitting the fibrous capsule anteriorly so that the adventitia of the ureter is visible. For this, the console surgeon employs Gyrus PK bipolar graspers in the left hand and robotic Potts scissors in the right. The assistant uses a combination of laparoscopic Maryland graspers and the suction-irrigator to retract tissue and clear the field of blood and fluid. After identifying the anterior ureter, the remaining ureter is circumferentially released from the fibrous reaction using a combination of blunt and sharp dissection, avoiding the use of electrocautery around the ureter (Fig. 13.9). The ureter should bluntly peel out of the fibrotic rind once the correct plane is established. The fourth arm creates traction by advancing the Vessiloop and placing the ureter on stretch anteriorly (Fig. 13.10). The robotic surgeon places counter traction with a blunt dissector, and the Potts scissors are used to sharply release any adherent tissue and to sharply sweep the ureter out of the fibrotic reaction. It is important to completely mobilize the ureter from this dense tissue and be sure that healthy ureter is identified proximally and distally. It is not uncommon for the ureter to appear ischemic or congested once lysed.

Upon completing the robotic ureterolysis , attention is now paid to the omental wrapping. The surgeon uses Gyrus PK bipolar graspers in the left hand and ProGrasp™ forceps in the right, while the assistant uses atraumatic graspers to expose and isolate the omentum. Once the omentum is identified, the assistant employs either a 5 mm Ligasure (Valleylab, Boulder, CO) or an Ethicon harmonic scalpel to harvest the omental pedicle. The most distal portion of the pedicle is brought underneath the ureter and tacked to the sidewall with either Hem-o-lok^® clips or a 2-0 polyglactin suture (Fig. 13.11). Next, the lateral pedicle is tacked to the sidewall, allowing the entire omental flap to lay posterior to the ureter. The medial edge of the omentum, which is also medial to the ureter, is now wrapped anterior to the ureter and tacked to the sidewall (Figs. 13.12 and 13.13). At the end of the operation , a closed suction drain is placed near the omental wrap.

The operative site and omentum are examined for bleeding under low insufflation pressure, and hemostasis is achieved. The trocars are then removed under laparoscopic view. The 8 mm and 5 mm trocars generally do not require fascial closure but are simply closed subcutaneously.

Robotic ureterocalicostomy is indicated in patients with a proximal ureteral stricture and a scarred renal pelvis who have failed prior antegrade or retrograde endoscopic management, or in patients with an inaccessible intrarenal pelvis.

We prefer to have retrograde access to the bladder and ureter . For male patients, we use a flank position with the penis prepped into the field. In female patients, we prefer the semi-lateral decubitus with modified low-lithotomy.

Trocar configuration is described in detail above. Prior to docking, the table is maximally rotated down to allow gravitational mobilization of the intestines. The robot is then brought in perpendicular to table.