|Year : 2005 | Volume
| Issue : 2 | Page : 97-101
Robotic dismembered pyeloplasty for the treatment of ureteropelvic junction obstruction.
Director of Minimally Invasive Surgery, Urology Centers of Alabama, USA
Director of Minimally Invasive Surgery, Urology Centers of Alabama, 3485,Independence DR, Homewood, AL - 35242
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: Laparoscopic pyeloplasty has been shown to have equivalent surgical outcomes with less surgical morbidity when compared to the open approach. The laparoscopic approach has traditionally been performed in a few specialized training centers because of the advanced technical skills required to perform this complex reconstructive procedure. The introduction of robotic technology into the modern day operating suite has brought on a new era and has simplified complex urologic reconstructive procedures. The daVinci robot provides the advantages of three-dimensional vision, magnification, and a robotic articulating wrist. These features allow precise dissection and suturing capabilities. We used the daVinci robot to perform robotic assisted laparoscopic pyeloplasty. We studied its feasibility, utility, and efficacy. Methods: Between July 2002 and April 2003, 12 patients with a mean age of 29.2 years (16-56) underwent robotic assisted laparoscopic dismembered pyeloplasty. Each patient had presented with flank pain (six left and right) and had been diagnosed with a ureteropelvic junction (UPJ) obstruction by either IVP or MAG3 renal scan. A retrograde pyelogram was performed preoperatively to delineate the anatomy and a stent was placed. Robotic dismembered pyeloplasty was performed. Eight of 12 patients had crossing vessels only five of which were shown on preoperative CT scan. The crossing vessels were preserved in all cases. The UPJ was dismembered at the point of obstruction and the scar excised. The ureter was spatulated medially and the renal pelvis fashioned appropriately. Ureteropelvic reconstruction was performed with eight-interrupted 4-0 monocryl sutures on an RB-1 needle in the first five cases. In the other seven cases the anastomosis was performed with two running semicircular sutures. Stents were removed at 14-28 days. An IVP was performed prior to stent removal and a renal scan at 3 and 6 months. Results: Each patient underwent a successful procedure without open conversion, transfusion or complication. Estimated blood loss was minimal at 52 cm3. Each patient was discharged home on the first postoperative day, average 18 h. Operative times fell quickly as experience with the daVinci robot increased. Operative time averaged 201 min. The first five patient's average or time was 262 vs. 158 min for the last seven. Time for the anastomosis averaged 42 min (100-20). The initial five cases were performed with an interrupted anastomosis. These took longer averaging 65.4 min (100-33). The subsequent seven cases were performed with two running hemi-circumferential stitches with anastomotic time averaging 25 min (30-20). Intraoperatively no complications were noted. Postoperatively the average hospital stay measured from the time of surgery to the time of discharge averaged 18 h (24-16). No postoperative complications have been noted. Average return to work is 10.9 days, and clearance for full activity at 17 days. Duration of the stent has averaged 18 days (24-13). The initial five patients with the interrupted anastomosis had longer stent times of 22.2 days (28-17) while the patients with a running anastomosis has average stent times of 17.6 days (22-13). Average follow up is currently 4.9 months (2-10). Each patient is doing well with no signs of recurrent obstruction. Follow up has been documented with MAG3 renal scan with Lasix at 3, 6 and 9 months. Conclusion: The adoption of robotic technology into today's modern operating rooms has stimulated a new era in urologic surgery. The daVinci robot provides magnified three-dimensional vision and a miniature robotic articulating wrist that allows precise dissection and laparoscopic suturing. Robotic dismembered pyeloplasty is an excellent technique with very good results. As experience with the robotic instrumentation increases operative times fall quickly. Blood loss and pain are minimal, allowing early discharge home and quick recovery. The short-term results are promising. Longer follow-up is needed.
Keywords: Robotic, Pyeloplasty, Ureteropelvic junction obstruction
|How to cite this article:|
Patel V. Robotic dismembered pyeloplasty for the treatment of ureteropelvic junction obstruction. Indian J Urol 2005;21:97-101
Ureteropelvic junction (UPJ) obstruction is probably the most common congenital abnormality of the ureter, with a reported incidence of about five per 100 000 of the population. It occurs most commonly in children, males (5: 2) and on the left side (5: 2). The condition usually appears spontaneously, but the clustering of cases in some families suggests that there may be a genetic predisposition. It is also, often associated with other renal abnormalities, such as contralateral renal agenesis, ectopic position, duplication of the collecting system, multicystic dysplastic and horseshoe kidney.
Pyeloplasty is the current gold standard for treatment of UPJ obstruction. Kuster reported the first successful open pyeloplasty in 1891. Since that time many different open approaches have been developed; of these the Anderson-Hynes dismembered pyeloplasty has become the most popular. Open pyeloplasty has been shown to have excellent success rates in excess of 90%; however, it is associated with significant morbidity and a prolonged recovery period due to the generous flank incision. Therefore, other less morbid approaches have been sought. Laparoscopic pyeloplasty was first performed in the early 1990s and was developed to provide a less invasive approach to UPJ reconstruction. ,,,,, The laparoscopic approach has shown success rates equivalent to that of the open surgery. However, it has taken time to gain favor because initially it was associated with prolonged operative times and a steep learning curve. The difficulty associated with laparoscopic pyeloplasty is due to the complex intracorporeal suturing skills that are necessary for a successful reconstruction. Over recent years improved technology and surgical technique has lead to a decrease in operative times allowing laparoscopic pyeloplasty to challenge the open approach as the gold standard. Currently the procedure is not universally applied because outside of specialized centers the technical challenges of laparoscopy remain, limiting its overall availability and use.
The introduction of robotic technology into today's modern day operating theatres has heralded a new era in urologic surgery. These recent advances have been applied to enhance the field of surgical laparoscopy. The daVinci robotic system (Intuitive Surgical, Sunnyvale, CA, USA) provides a distinct surgical advantage over conventional open or laparoscopic surgery; including magnified three-dimensional vision and an articulating robotic wrist with seven degrees of freedom (DOF). These advancements are particularly apparent when performing any laparoscopic reconstructive procedure that requires suturing. After amassing a considerable amount of experience with the pure laparoscopic pyeloplasty we used the daVinci to perform robotic assisted laparoscopic dismembered pyeloplasty. We present our results herein.
| Materials and methods|| |
Between July 2002 and May 2003, 12 patients six males and six females with a mean age of 29.2 years (16-56) underwent robotic assisted laparoscopic dismembered pyeloplasty. All presented with renal colic, two also had kidney stones. Each patient underwent IVP in the emergency room for initial diagnosis. During the subsequent evaluation a triple phase CT scan was performed to ascertain if a crossing vessel was present. A MAG3 renal scan with Lasix was also performed to assess the degree of obstruction and renal function. Average preoperative T1/2 was 30 min and renal function averaged 39% on the affected side.
Prior to surgery each patient obtained medical clearance from his or her primary physician. Basic laboratory tests were also performed to assess the patient's ability to undergo surgery. These included: a urine culture, complete blood count, basic chemistry panel and a coagulation profile. One and half hour before surgery the patient is infused intravenously with 1gm of cefazolin or 500 mg of levofloxin.
General endotracheal anesthesia is administered. The patient is placed in stirrups and a cystoscopy, retrograde pyelogram and stent placement is performed under fluoroscopic guidance. The retrograde pyelogram provides an essential road map to the location and anatomy of the UPJ. A stent length one size longer than would usually be placed for that individual is helpful because it prevents the distal tip of the stent from being pulled up into the ureter during dissection.
Operative set up
After cystoscopy the patient is repositioned and placed in a modified lateral decubitus position at 45° to the table and is held in place with a bean bag. The upper arm is held in suspension with a padded arm hanger. The lower arm is partially flexed on a padded arm board. An axillary role is placed and the lower extremities are padded with the bottom leg bent at 45° and the top leg straight with a padding in between. The patient is then strapped into place and secured with 3² silk tape.
The trocars are placed as shown in under direct laparoscopic vision. Intra-abdominal access is obtained at the umbilicus through either a veress or hasson technique and a long 12 mm trocar is placed for the laparoscope. The abdomen is insufflated to 15 mm of pressure. For the daVinci surgical system special 8 mm trocars are placed directly lateral to the umbilical trocar. The trocars must be placed at least between 8 and 10 cm away in order to prevent the robotic arms from obstructing against each other. An accessory 10 mm port is also placed on the contralateral portion of the abdomen about 2 cm from the midline between the umbilical and subcostal trocars. This trocar is placed contralaterally because the robot comes in ipsilateral to the side of obstruction over the shoulder leaving little room for the assistant to work on that side.
Dismembered robotic pyeloplasty
The robot is advanced to the patient on the ipsilateral side to the obstruction and docked to the trocars securely. The laparoscope is inserted through the umbilical trocar and the robotic arms are extended through the daVinci ports. A robotic cardiere grasper is placed in the left daVinci arm and a hook cautery in the right. The colon and its mesentery are then reflected medially. At the lower pole of the kidney the psoas muscle is exposed and medial dissection identifies the stented ureter. The ureter is then dissected proximally to the renal pelvis preserving collateral vessels. The level of UPJ obstruction is identified. The renal pelvis is then dissected free of any surrounding fibrous tissue and all crossing vessels preserved. Once the proximal ureter and renal pelvis are fully mobilized the ureter is dismembered at the site of UPJO. The hook cautery is replaced with an articulating robotic scissors that is used for dismemberment and for lateral spatulation of the ureter. The articulation of the robotic wrist of the scissors allows for easier spatulation. The renal pelvis is then modified to the appropriate size.
If an anterior crossing vessel is present the renal pelvis and ureter are transposed over it and the vessel regresses posteriorly. The anastomosis is then performed using robotic needle drivers with running or interrupted suture. The anastomosis is begun with 4-0 absorbable suture (monocryl or vicryl on RB1 needle) at the apex of the spatulated ureter, first completing the posterior wall and then the anterior wall. For interrupted anastomosis between 7 and 10 sutures can be placed. With a continuous stitch two 12-cm long sutures are tied together and then run continuously in opposite directions from posterior to anterior starting at the apex of the ureteral spatulation. The stent is repositioned into the renal pelvis at the appropriate time once the anastomosis is close to completion. An abdominal Jackson Pratt drain is placed.
On the day of surgery the patient is placed on a clear liquid diet, morphine or Demerol for pain control and is ambulated the evening of surgery. The next morning the Foley catheter is removed. The patient is then discharged home on the first postoperative day if their pain is controlled with oral narcotic, they are able to ambulate without assistance and can tolerate a diet. The patient returns on postoperative day 3 for JP removal. The drainage has been uniformly minimal averaging less than 100 cm3/24 h.
| Results|| |
To date 12 robotic pyeloplasties have been performed at our institution. The results are shown in [Table - 1]. Average operative time was 201 min (330-150). Operative time decreased significantly as the surgeon's experience with the daVinci robot increased. The first five cases averaged 262 min. While the last seven averaged 159 min. The blood loss was minimal 58.3cm3 (100-25). All crossing vessels were preserved. Eight of 12 patients had crossing vessels only five of which were shown on preoperative CT scan. The crossing vessels were preserved in all cases. Time for the anastomosis 42 min (100-20) improved with experience also. The initial five cases were performed with an interrupted anastomosis 65.4 min (100-33). The subsequent seven cases were performed with two running hemi-circumferential stitches with anastomotic time averaging 25 min (30-20). Intraoperatively no complications were noted. Postoperatively the average hospital stay measured from the time of surgery to the time of discharge was 18 h (24-16). In all patients the Foley catheters were removed prior to discharge home. JP drains were removed on postoperative day 3 in the office. Average JP output was 150 cm3 for those patients with an interrupted anastomosis and 75 cm3 for those with a running.
No postoperative complications have occurred. Average return to work is 10.9 days, and clearance for full activity at 17 days. Duration of the stent has averaged 18 days (24-13). The initial five patients with the interrupted anastomosis had longer stent times of 22.2 days (28-17) while the patients with a running anastomosis has average stent times of 18 days (22-13).
Prior to stent removal each patient had an IVP to confirm healing of the collecting system. No leaks were seen on IVP. Stents were removed in the office with flexible cystoscopy. Repeat stenting has not been necessary. One month after stent removal a MAG3 renal scan with Lasix is performed to evaluate renal drainage and function. This study is then repeated at 3-month intervals. In each patient the study has revealed adequate renal drainage indicating a successful reconstruction. Excretory half life has been shown to decrease in all patients. Renal function has remained the same or improved in all patients when compared to preoperative function.
Average follow up is 4.9 months (2-10). No patient has demonstrated repeat obstruction. MAG 3 renal scans at 3, 6 and 9 months postsurgery demonstrate improved drainage and equal or improved function to the preoperative study. Average return to work is 10.9 days, and clearance for full activity at 17 days.
| Discussion|| |
Open dismembered pyeloplasty is the most commonly performed operation for treatment of UPJ obstruction with success rates exceeding 90% in contemporary series., However, the significant surgical morbidity associated with an open flank incision along with the extended recovery period has lead to the development of various minimally invasive treatment modalities. Percutaneous antegrade and endoscopic retrograde approaches have also been shown to be relatively effective for UPJ obstruction and are associated with shortened hospital stays and rapid recovery. However, these techniques have a 10-25% lower success rate in comparison with open pyeloplasty and can be associated with increased risks of hemorrhage. The success rates of these incisional techniques are further reduced with other associated abnormalities. Van Cangh et al. noted a 44% decrease in success when antegrade endopyelotomy was performed in the presence of a crossing vessel. Merz et al. noted that endopyelotomy failures were associated with significantly larger pelvicaliceal volumes. The combination of a large redundant and crossing vessel has been reported to decrease the overall success rate of endopyelotomy to 39%.
Laparoscopic pyeloplasty has now been performed for over a decade with increasing technical proficiency; therefore, it has begun to challenge the open approach as the gold standard for treatment of UPJ obstruction. Larger series show comparable success rates to open surgery [Table - 2]. ,,,,,, Soulie et al. have the largest published series of laparoscopic pyeloplasty. Fifty-five cases performed via an extraperitoneal approach. Operative time averaged 185 min. Success rate was 88.9% with a follow up of 14.4 months. Moore et al. published a series of 30 patients who underwent transperitoneal laparoscopic pyeloplasty. This was one of the early series with operative time averaging 370 min with a 97% success rate at an average of 16.3 months follow up. Laparoscopic pyeloplasty has been shown to be feasible with excellent success rate. However, the introduction of this technique into mainstream urologic practice has been hindered by the technical challenges provided by laparoscopic suturing. Until now the procedure has been confined to specialized centers proficient in laparoscopy.
The introduction of robotic technology with its magnified three-dimensional vision and articulating robotic wrist has made laparoscopic pyeloplasty technically easier. The daVinci robot with its 7 DOF has made laparoscopic suturing intuitive reducing the technical challenge significantly. The daVinci robot (Intuitive Surgical, Sunnyvale, CA, USA) operates on a master slave relationship. The master slave system is one in which the operator manipulates a 'master' device from a surgical console using a type of joystick whose movements are translated to comparable movements in the 'slave' robot performing the task. These technologic advancements have provided certain inherent advantages over open and traditional laparoscopic surgery. These advantages have led us to transition from the pure laparoscopic approach to the robotic assisted approach.
We chronicle one of the first reported series evaluating the feasibility and efficacy of robotic assisted laparoscopic pyeloplasty. We performed twelve pyeloplasties successfully. The initial cases have prolonged operative times as the operative team learns to work together and understand the nuances unique to robotic surgery. The initial difficulties included patient positioning, trocar placement, and docking of the robot to the laparoscopic trocars. The trocar placement is slightly varied from the pure laparoscopic approach, as one has to take into account the arrangement of the daVinci robotic arms. The laparoscope is always placed in the 12 mm center port with the arms going in via the 8 mm robotic arms. As experience increased docking times came down quickly. Initial operative times were also prolonged by the novelty of the remote surgeon and lack of tactile sensation. The surgeon who is isolated from the patient learns to work with surgical colleagues at the patient bedside. As experience increases the surgeon learns to appreciate subtle visual clues that allow one to overcome the lack of tactile sensation by learning to 'feel with his/her eyes'. The surgeon has no true tactile sensation; however, the magnification and three-dimensional vision facilitates the surgeons heightened awareness of visual clues mimicking tactile sensation. This concept can take quite some time to appreciate.
As surgeon comfort with the procedure and use of the robot increases operative times decrease. Our operative times averaged 201 min. The first five cases took an average of 262 min and the last seven 159 min. The advantage of the robot is seen most effectively during the ureteropelvic anastomosis. The robotic wrist facilitates laparoscopic suturing making it intuitive. The difficulties seen with straight laparoscopic suturing including placement of sutures and tying are not seen as readily. The learning curve for robotic suturing vs. laparoscopic is significantly reduced. One is able to control the needle and suture with either arm placing the needle at almost any angle. As one transition from an interrupted to a running anastomosis time is also decreased. In the last seven cases anastomotic times averaged only 25 min.
The advantages of robotic pyeloplasty are those of the laparoscopic approach, which include: less blood loss, decreased pain, shortened hospital stay and faster recovery. In addition our data shows shorter stent times and an even shorter hospital stay compared to those of pure laparoscopic series, [Table - 2]. Average stent time in most laparoscopic series is 28 days. Our series averaged 18 days. This is possibly due to greater confidence in the anastomosis. Hospital stay is also very short as patients experience minimal discomfort and blood loss. In our series hospital stay averaged about 18 h postsurgery. While currently open surgery remains the gold standard for UPJ obstruction the gap is being closed quickly as more and more surgeons learn laparoscopic techniques. Success rates are equivalent and operative times are falling quickly. The inherent advantages of laparoscopic surgery including less blood loss, pain, and quicker recovery are significant. The addition of robotic technology to the urologist armamentarium will only serve to hasten the universal adoption of robotic assisted laparoscopic pyeloplasty for UPJ obstruction.
| Conclusions|| |
Laparoscopic pyeloplasty is a complex reconstructive procedure that requires technical expertise. The procedure, which was once limited to only a few specialized centers is becoming more widespread. The laparoscopic approach is advantageous because it provides an excellent surgical outcome while decreasing patient morbidity. The adoption of robotic technology into today's modern operating rooms has stimulated a new era in urologic surgery. The daVinci robot provides magnified three-dimensional vision and a miniature robotic articulating wrist that allows precise dissection and laparoscopic suturing. Robotic dismembered pyeloplasty is an excellent technique with very good results. As experience with the robotic instrumentation increases operative times fall quickly. Blood loss and pain are minimal, allowing early discharge home and quick recovery. The short-term results are promising. Longer follow-up is needed.
| References|| |
|1.||Murphy LJT: The kidney, in Murphy LJT: The History of Urology. Springfield, Illinois 1972;201-32. |
|2.||Anderson JC, Hynes W. Retrocaval ureter. A case diagnosed preoperatively and treated successfully by a plastic operation. Br J Urol 1949;21:209. |
|3.||Brooks JD, Kavoussi LR, Preminger GM. Comparison of open and endourologic approaches to the obstructed ureteropelvic junction. Urology 1995;46:791-5. |
|4.||Janetschek G, Peschel, R, Franscher F. Laproscopic pyeloplasty. Urologic Clinics of North America 2000;27. |
|5.||Moore RG, Averch TD, Schulam PG, Adams JB 2nd, Chen RN, Kavoussi LR. Laparoscopic pyeloplasty: experience with the initial 30 cases. J Urol 1997;157:459-62. |
|6.||Ben Slama MR, Salomon L, Hoznek A, Cicco A, Saint F, Alame W et al. Extraperitoneal laparoscopic repair of ureteropelvic junction obstruction: initial experience in 15 cases. Urology 2000;56:45-8. |
|7.||Soulie M, Salomon L, Patard JJ. J Urol 2001;166:48-50 |
|8.||Janetschek G, Peschel R, Altarac S, Bartsch G. Laparoscopic and retroperitoneoscopic repair of ureteropelvic junction obstruction: Urology 1996;47:311-6. |
|9.||Eden CG, Cahill D, Allen JD. Laparoscopic dismembered pyeloplasty: 50 consecutive cases. British Journal of Urology 2001;88:526-31. |
|10.||Bauer JJ, Bishoff JT, Moore RG. Laparoscopic versus open pyeloplasty: Assessment of objective and subjective outcome. J Urol 1999;162:692. |
|11.||Stoianovici D, Caddedu JA, Kavoussi LR. Urologic applications of robotics. AUA update series lesson 1999;25:XVIII. |
|12.||Scardino PT, Scardino PL. Obstruction at the ureteropelvic junction, in Bergman H (Ed): The Ureter, New York, Springer-Verlag 1981;697-716. |
|13.||Goldfischer ER, Smith AD. Endopyelotomy revisited. Urology 1998;51:855-8. |
|14.||Eden CG. Treatment options for pelvi-ureteric junction obstruction: implications for practice and training. British Journal of Urology 1997;80:365-72. |
|15.||Van Cangh PJ, Wilmart JF, Opsomer RJ, Abi-Aad A, Wese FX, Lorge F. Long term results and late recurrence after endoureteropyelotomy: a critical analysis of prognostic factors. J Urol 1994;152:934-7. |
|16.||Merz VW, Turner W, Zingg et al. Impact of pelvicalyceal size on the success rate of endopyelotomy. J Urol 1994;151:394. |
|17.||Recker F, Subotic B, Goepel M. Laparoscopic dismembered pyeloplasty. J Urol 1995;153:1962-5. |
|18.||Schuessler WW, Grune Mt, Tecuanhuey LV. Laparoscopic dismembered pyeloplasty. J Urol 1993;150:1795-7. |
[Table - 1], [Table - 2]