International Journal of Urology (2008) 15, 744–746 doi: 10.1111/j.1442-2042.2008.02091.x Short Communication Robot assisted laparoscopic pyeloplasty in patients of ureteropelvic junction obstruction with previously failed open surgical repair Ashok K Hemal, Saurabh Mishra, Satydip Mukharjee and Manav Suryavanshi Department of Urology, All India Institute of Medical Sciences, New Delhi, India Abstract: To review our experience of robotic redo pyeloplasty as a salvage procedure in previously failed repair of ureteropelvic junction (UPJ) obstruction. In one year, robot-assisted laparoscopic pyeloplasty was performed in nine patients for previously failed open pyeloplasty. Four of these patients had undergone additional retrograde endopyelotomy following failed repair, prior to being referred to us. The mean age was 16.4 years. All patients presented with persistent flank pain and an obstructive pattern on diuretic renogram. Robotic redo pyeloplasty could be performed successfully in all patients without any technical problems. Intraoperative findings for cause of UPJ obstruction were peri-ureteral fibrosis, narrow ureter, anterior crossing vessels, and redundant pelvis. The mean hospital stay was 3.4 days (2–5 days). All patients had improvement in symptoms and the nuclear scan showed non-obstructive drainage. Robot assisted redo pyeloplasty enables complex repair in patients with previous failed cases of UPJ obstruction repair. Three-dimensional magnified vision, and a dynamic articulated endowrist, allows fine dissection in the fibrosed area and precise suturing in an ergonomic fashion with a success equivalent to open surgery. Key words: kidney, laparoscopic pyeloplasty, open pyeloplasty, robot, UPJ obstruction. Introduction Open dismembered pyeloplasty is a gold standard for managing ureteropelvic junction (UPJ) obstruction resulting in a success rate >90%.1 Conventional open surgery for failed pyeloplasty is very challenging because of the fibrosis and scarring at the previous surgical site and current options for managing the failed pyeloplasty are endopyelotomy or redo pyeloplasty which can be an open, laparoscopic or robot assisted approach. Both open and laparoscopic approaches have their advantages and disadvantages. The difficulty and technical challenge encountered during the dissection of such cases with pure laparoscopy can be minimized with the help of robotic assistance. Herein, we present our experience of robot assisted redo pyeloplasty in patients with prior failed open pyeloplasty. Methods Nine patients with previous failed open pyeloplasty underwent robotic redo pyeloplasty to salvage the function of the kidney with da Vinci –S robotic system. In all patients antegrade stenting was done. Demographic details of the patients undergoing robotic pyeloplasty are shown in Table 1. Four of these patients also had history of retrograde endopyelotomy following failure of their open pyeloplasty. These patients had presented with persistent flank pain, ipsilateral hydronephrosis on ultrasonography of the abdomen and an obstructive pattern on diuretic renal dynamic scan. Pre-operative retrograde pyelogram was performed in all cases so as to ascertain the anatomy of the ureter and Correspondence: Ashok K Hemal MS DipNB MCH MAMS FICS FACS FAMS FRCS (Glasg), Department of Urology, and Institute of Regenerative Medicine, Robotics and Minimally Invasive Surgery, Baptist Medical Center, and Wake Forest University School of Medicine, Wake Forest University Health Sciences, Medical Center Boulevard , Winston-Salem, NC 27157-1094, USA. Email: ahemal@wfubmc.edu Received 22 December 2007; accepted 17 April 2008. 744 pelvis. Redo robot assisted modified Anderson-Hynes pyeloplasty was performed transperitoneally with five ports (three robotic and two 5 mm for assistance) in all cases. The robotic set up is demonstrated in Figure 1. The daVinci-S robot was positioned on the ipsilateral back side of the patient and was docked. In two patients duodenum was adhered to the UPJ which was carefully released. Before starting surgery, we gave 20 mg of furosemide to produce brisk diuresis, so as to make the dilated pelvis obvious for identification. Adhesions were present in all cases, so we had to perform adhesiolysis releasing the gut and omentum. We then mobilized the ipsilateral gut to expose the retroperitoneal area. The ureter was identified in the virgin field , significantly below the UPJ. Careful dissection was then performed upward to expose the renal pelvis using blunt and sharp dissection with the help of Maryland bipolar forceps and monopolar hot scissors that released the surrounding fibrosed tissue. Thereafter, the ureter and pelvis were transected with an excision of the fibrosed segment. The spatulation of the ureter on the lateral side, and substraction of the redundant renal pelvis was carried out in all cases. Transposition of crossing vessels was carried out in addition in two cases. Modified Anderson-Hynes pyeloplasty was performed in all patients using a 4-0 or 5-0 polydiaxone suture. The sutures were applied in interrupted and also in continuous fashion based on the situation of the flaps, surrounding tissue and vascularity. In all the patients antegrade stenting was performed intraoperatively through a 5 mm working port over a Terumo guide wire. Drain was placed in 6 patients only. The drain and Foley catheter were removed on postoperative day 1 and 2 respectively. The stent was removed at 4 weeks. A follow-up ultrasonogram (USG) abdomen and renal dynamic scan was performed after removing the stents at 6 months and annually. We used the robotic port for passing sutures to avoid making a 12 mm port for assistance. Results The procedure was successful in all nine cases (Fig. 2a, 2b). Results are summarized in Tables 1 and 2. There were no intraoperative © 2008 The Japanese Urological Association Robotic pyeloplasty in failed UPJ repair Table 1 1 2 3 4 5 6 7 8 9 Mean Demographic profile of patients Age/sex Side Duration since previous pyeloplasty Renal function Intraoperative findings 16 years/M 12 years/M 20 years/F 26 years/M 36 years/M 14 years/F 14 years/M 13 years/F 10 years/M 17.9 years Left Left Right Left Left Left Right Right Left 10 months 22 months 6 months 14 months 11 months 9 months 8 months 10 months 3 months 10.3 months 22.5% 32% 18% 45.4% 40.4% 28.5% 22% 36.8% 44% 32.2% Crossing vessel Adhesions, surrounding fibrosis Adhesions , surrounding fibrosis Adhesions , surrounding fibrosis Crossing vessels Adhesions, 2 cm upper ureter stricture Redundant pelvis, folded at UPJ Adhesions , fibrosis Adhesions, fibrosis Fig. 1 Placement of ports and docked robot for left side robotic pyeloplasty. complications. Postoperatively, one patient developed fever. All the patients had improvement in symptoms and the nuclear scan showed non-obstructive drainage in all patients. Discussion The first successful pyeloplasty was reported in 1891. Since then it has become the gold standard as management for primary UPJ obstruction resulting in a success rate of more than 90%.1 During the last decade, a laparoscopic approach has established its role in many surgical procedures including pyeloplasty with its well established advantage of reduced pain, reduced hospital stay and reduced morbidity. Its disadvantage is the long learning curve involved. We had reported that most UPJ obstructions can be cost-effectively managed laparoscopically including those that have failed endopyelotomy or have a dilated renal pelvis, coexisting renal calculous disease, abnormalities of position or rotation, and those with associated crossing vessels.2 Although the laparoscopic technique mimics open surgery, it is not as versatile, however, and it becomes technically more challenging in cases of failed pyeloplasty. With the availability of the robot at our institute, we explored its potential use in these difficult situations. The robotic system has additional advantages over a laparoscopic approach as it offers three-dimensional visions with increased magnification and © 2008 The Japanese Urological Association depth of perception; it filters tremors; it allows for adjustable scaling of the surgeon’s motion; and prevents the surgeon’s fatigue. The dynamic versatility of the endowrist allows easy intracorporeal suturing in a magnified 3-D environment. All of theses features result in an easier reconstructive procedure compared to straight laparoscopy. The common causes of failure of open pyeloplasty are peripelvic fibrosis, an excess amount of scarring due to urinary extravasation, excess use of thermal energy, and lasers or urinary extravasation, and bleeding during endopyelotomy which can cause more tissue reaction and fibrosis.3 The other common factor is inability to detect lower pole crossing vessels at the initial procedure.4 In the present series, the causes for failure were peripelvic fibrosis and scarring in six cases (66.7%), missed lower pole crossing vessels at initial surgery in two (22.2%) and redundant pelvis with a kink at the UPJ in one. The available options for management of failed pyeloplasty are balloon dilatation, antegrade and retrograde endopyelotomy and redo pyeloplasty. Due to the inconsistent long term results of balloon dilation and endopyelotomy5,6 and their role in selected cases (pelvis volume <70 ml, renal function >30% and no crossing vessels) we preferred redo pyeloplasty in failed previous pyeloplasty patients. Redo pyeloplasty following failed primary open pyeloplasty is difficult.7 In a series of open redo surgical repair of failed previous pyeloplasty, 13 underwent redo pyeloplasty while three underwent ureterocalycostomy. The surgeons used a nephrostomy tube in all patients in comparison to the present series where none of the patients required a nephrostomy tube. Similarly, a drain was used in all of their patients, unlike the present series where we could do without in some of our cases because we could perform water tight anastomosis with out any complication.8 Chandru et al.9 demonstrated that the difficulties associated with redo laparoscopic pyeloplasty following failed primary open pyeloplasty can include a long operative time: the mean operative time required in their series was 6.2 h. Clayman et al.10 also reported their experience of laparoscopic pyeloplasty in four patients of secondary UPJ obstruction in whom anterior crossing vessel was the cause of obstruction. The average operating time was also quite long (9.05 h). Robotic assistance significantly reduces the operative time for robot assisted laparoscopic redo pyeloplasty. We could achieve a success rate up to 100% in the present series, however a long term follow up of 3–5 is years required and more cases are needed in the study. The real benefits we saw with robotic assistance in laparoscopic redo pyeloplasty are ease in meticulous dissection, better delineation of the previous scarred tissue, preservation of the periureteral sheath containing blood supply to the ureter, clean and fine fashioning of ureteral and 745 AK HEMAL ET AL. Table 2 Results Intraoperative findings Dense adhesions Crossing vessels Redundant pelvis Mean surgical time (min) Mean blood loss (ml) Mean hospital stay (days) Complications Intraoperative Postoperative Fever Mean follow up (months) 6 2 1 106 (95–150) 72.4 (40–200) 3.4 (2–5) nil 1 7.4 (2–15) tomies and balloon dilatation have increased the role of redo pyeloplasties in such patients. Robot assisted redo pyeloplasty results in an excellent success rate equivalent to open surgery with minimal morbidity. We expect it to become an alternative treatment modality in future for failed cases of pyeloplasties, although more long-term studies with a larger number of patients are required before it becomes the standard of care. References Fig. 2 (a) Preoperative intravenous urogram showing left sided ureteropelvic junction obstruction. (b) Preoperatively intravenous urogram showing robotically repaired left sided ureteropelvic junction obstruction. pelvic flaps, and finally, in executing water tight anastomosis with fine sutures. Conclusion The management of failed pyeloplasty is technically very challenging. The low success rates of minimal invasive procedures like endopyelo- 746 1 O’Reilly PH, Brooman PJ, Mak S et al. The long-term results of Anderson-Hynes pyeloplasty. BJU Int. 2001; 87: 287–9. 2 Hemal AK, Goel R, Goel A. Cost-effective laparoscopic pyeloplasty: single center experience. Int. J. Urol. 2003; 10: 563–8. 3 Persky L, McDougal WS, Kedia K. 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Urol. 1997; 158: 1257–9. 9 Sundaram CP, Grubb RL 3rd, Rehman J et al. laparoscopic pyeloplasty for secondary ureteropelvic junction obstruction. J. Urol. 2003; 169: 2037–40. 10 Nakada SY, Mcdougall EM, Clayman RV. Laparoscopic pyeloplasty for secondary ureteropelvic junction obstruction: preliminary experience. Urology 1995; 46: 257–60. © 2008 The Japanese Urological Association