Navigating the Difficult Robotic Assisted Pyeloplasty

Pyeloplasty is the gold standard therapy for ureteropelvic junction obstruction. Robotic assisted pyeloplasty has been widely adopted by urologists with and without prior laparoscopic pyeloplasty experience. However, difficult situations encountered during robotic assisted pyeloplasty can significantly add to the difficulty of the operation. This paper provides tips for patient positioning, port placement, robot docking, and intraoperative dissection and repair in patients with the difficult situations of obesity, large floppy liver, difficult to reflect colon (transmesenteric pyeloplasty), crossing vessels, large calculi, and previous attempts at ureteropelvic junction repair. Techniques presented in this paper may aid in the successful completion of robotic assisted pyeloplasty in the face of the difficult situations noted above. 1. Introduction Pyeloplasty is the gold standard therapy for ureteropelvic junction obstruction (UPJO), with reported success rates approaching 90% [1]. Urology has embraced the da Vinci surgical system (Intuitive Surgical, Inc., Sunnyvale, CA, USA) for complex reconstructions of the urinary tract, including pyeloplasty. Success rates of robotic assisted pyeloplasty (RAP) appear to be equivalent to open pyeloplasty while conferring the well-published advantages of minimally invasive surgery (decreased postoperative pain, shorter hospital stay, quicker return to normal activities, etc.) [1–3]. Situations encountered during RAP can significantly alter surgical difficulty and possibly contribute to surgical morbidity. Obesity, large floppy liver, unretractable colon, crossing vessels, large calculi, and previous attempts at UPJO repair can all present a significant intraoperative difficulty. This paper describes techniques to aid in the successful completion of RAP if these situations are encountered. 2. Standard Technique The standard patient positioning, port placement, colon mobilization, UPJO dissection, repair, and stent placement as well as postoperative management of RAP have been well described [4]. The patient is placed in a 70-degree flank position with the ipsilateral arm secured above the head on an arm board. A cystoscopically placed stent-wire complex is anchored to a urethral catheter and prepared in the sterile operative field. Standard port placement is demonstrated in Figure 1. The colon and its mesentery are reflected medially to reveal the underlying kidney, renal pelvis, and ureter. The renal pelvis and proximal ureter are freed of their surrounding attachments with care taken to avoid excessive manipulation