Complex pelvic-ureteric junction obstruction (PUJO): successful management with robotic assistance

Robot-assisted laparoscopic pyeloplasty: A retrospective case series review

Introduction

Anderson-Hynes pyeloplasty has been gold standard in the management of pelviureteric junction obstruction (PUJO). It has evolved from open to laparoscopic and now robotic surgery. Open surgery has its drawback of long incision and scar mark, significant post-operative pain and long hospital stay. The main limitation of laparoscopic surgery had been the difficulty in endosuturing. Robotic surgery has incorporated the minimal access method of laparoscopy and endowrist movement of open surgery to overcome the challenge of intracorporeal suturing. Here, we present our initial experience of robotic pyeloplasty.

Patients and Methods

A total of 30 patients underwent robot-assisted laparoscopic pyeloplasty (RALP) over 19 months. Diagnosis of PUJO was made by computed tomography urography, diuretic renogram and retrograde pyelogram in selected patients. All patients underwent RALP by colon reflecting approach. Post-operative evaluation was done by DTPA scan at 3- and 6-month follow-up. Data were analysed after a mean follow-up of 11 months.

Results

The mean operative time was 148 min and the mean hospital stay was 3.5 days. While 93% of the patients showed objective improvement in their drainage pattern on DTPA renogram, 90% of the patients were symptom-free at the end of 6 months.

Conclusions

Robotic pyeloplasty is a safe and easily conquerable technique with comparable outcomes in the hands of surgeons who are beginners in this technique.

Outcomes of Robot-Assisted Ureterocalicostomy in Secondary Ureteropelvic Junction in Adults: Initial Experience Using Da Vinci Xi System with Near-Infrared Fluorescence Imaging

Aim: To report the surgical technique and early outcomes of robot-assisted ureterocalicostomy (RAUC) with near-infrared fluorescence (NIRF) in the management of secondary pelvi-ureteric junction obstruction (PUJO) in adults. Materials and Methods: The data of 6 patients who underwent RAUC using Da Vinci Xi system with NIRF technology between November 2017 and April 2019 were retrospectively reviewed. Indication was secondary PUJO due to previous failed pyeloplasty. The outcome variables evaluated include operative time (total and console), length of hospital stay, blood loss, and complications. Success was defined as the absence of pain and radionuclide scan demonstrating nonobstructive drainage and improvement/stabilization of split function of the renal moiety. Results: The mean (range) patient age was 33.7 (18-41) years. Total mean (range) operating time was 178 (140-240) minutes and mean console time was 135 minutes. Estimated mean blood loss was 115 (50-200) mL and average hospital stay was 6.1 (5-8) days. There were no conversions to open or laparoscopic surgery. Clavien-Dindo complications occurred in 2 patients. (Grade I-1 and Grade II-1). After a median (range) follow-up of 15 (6-22) months, all 6 patients had successful clinical and radiological outcomes. Conclusion: RAUC is a safe and feasible technique with acceptable outcomes in the setting of secondary PUJO. The utility of NIRF in determining vascularity of the ureter seems to be promising in this setting. Multi-institutional prospective studies with large patient cohort are necessary to validate the role of robotic platform in ureterocalicostomy in the reoperative settings.