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- What is a robotic pyeloplasty?
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What is a robotic pyeloplasty?
As with prostatectomy, the best way to answer this question is with a history lesson of surgery to repair a condition known as ureteropelvic junction obstruction, or UPJ obstruction. UPJ obstruction is most commonly a congenital blockage of the kidney at the point where the kidney connects to its drainage tube, the ureter. Most of these congenital narrowings are detected as dilation of the kidney during a prenatal ultrasound, so most are therefore caught and followed or repaired in very young children. Although robotic surgery is starting to be applied to the operation to correct this blockage in children, a pyeloplasty, this is usually repaired relatively simply through a small incision. Robotic surgery is still a very rare event in children.
Some UPJ obstructions do escape detection and are found in younger adults. In this age group, our experience has been that the obstruction if less likely to be congenital and far more likely to be caused by unusual vascular anatomy such as an extra blood vessel feeding the lower pole of the kidney. This is called a crossing vessel, and is usually an artery but can rarely be a vein. In this case, as these vessels enlarge with the patient, they can sit on the ureter and cause relative obstruction and dilation. The patient will have pain in his/her side, especially when drinking large amounts of fluid or alcohol. If UPJ obstruction is diagnosed, then it usually must be surgically corrected.
Until perhaps fifteen years ago, this correction was performed through an incision call a flank incision. This is a painful incision in adults as opposed to children, but the operation is a relatively simply one. The goal is to identify the cause of the blockage, remove the blockage, and reconstruct the urinary tract over the crossing vessel if present. The first attempts at being minimally invasive were operations done through a tube place into the kidney through the back called a nephrostomy. Through this, a scope could be placed and a small knife used to cut open the narrowing from the inside. Later devices, such as the Accucise endopyelotomy device, were developed to be able to do this from the bladder, thus avoiding having to place a nephrostomy. The advantage of these approaches were that they avoided the flank incision. The problems, however, were that they were not very successful in the setting of a crossing vessel, a common occurrence in adults, and that the long term success rate was perhaps only 50%. Also, performing the open operation after one of these procedures could be very difficult due to scarring.
When laparoscopy was developed, a surgical style involving small incisions and a video camera, this was applied to the pyeloplasty. This is an advance laparoscopic operation that involved skills that only a few select surgeons in each region usually possessed such as laparoscopic suturing and advanced dissection. Drs. Engel and Frazier have been pioneers in the field of Urologic laparoscopy in Washington D.C. and have been performing this procedure for years. A laparoscopic pyeloplasty is designed to be the same operation as the open procedure with a dramatically improved recovery time. Although patients still must be in the hospital for two days, they are fully recovered and back to work in a week or two versus the four to six weeks it takes to get over the flank incision. Success rates greater than 93% are achieved with the open or laparoscopic approach. Because of this, laparoscopic pyeloplasty has really become the first line therapy for UPJ obstruction in centers where it is offered.
As you have perhaps read elsewhere on this site, robotic surgery is simply a set of tools that is designed to take standard laparoscopy to a higher level. Suturing is simplified, and more advanced dissection in difficult cases are now possible. Therefore, a robotic pyeloplasty is really a laparoscopic pyeloplasty that utilizes the robotic instruments and visualization to perform certain tasks in the operation such as suturing. We always use the robot for pyeloplasty now, as we do for prostatectomy, because we feel that it is a tool perfectly suited for the reconstructive portions of this operation.
Once discharged, the patient will have a stent in the ureter and kidney for six weeks. The stent will be removed in the office at that point and the patient will return 8-12 weeks later with a renal scan that will hopefully show resolution of obstruction.