Pyeloplasty is a minimally invasive (laparoscopic) surgical procedure to correct narrowed or blocked Ureteropelvic Junction or UPJ due to a crossing blood vessel. Robotic Pyeloplasty is a laparoscopic pyeloplasty that utilizes robotic instruments for portions of the procedure that will take advantage of more precise sewing and reconstruction.
A Robotic Pyeloplasty is really a laparoscopic pyeloplasty that utilizes robotic instruments for portions of the procedure that will take advantage of its ability to allow for more precise sewing and reconstruction. As you will see in the videos below, Dr. Engel actually performs most of the robotic pyeloplasty without robotic instruments, and prefers to do most of the dissection strictly laparoscopically. In an adult practice, most pyeloplasties involve crossing lower pole arteries and/or veins that are obstructing the ureter, but occasionally a congenital defect or inflammatory lesion may be the problem. Also, not uncommonly the obstruction caused by a UPJ obstruction will cause stone formation, so there are times that stones will be removed as well at the time of the pyeloplasty.
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All patients will have undergone a formal bowel prep. Laparoscopic ports are placed triangulating the kidney, and the initial dissection is quite similar to a laparoscopic nephrectomy or partial nephrectomy. Here however, the dissection need not be carried out far beyond the main renal/kidney vessels such that the upper pole and back of the kidney are left attached. All of the blood vessels of the kidney are identified, as is the ureter and renal pelvis. The hope is to clearly delineate the crossing vessel/s causing the problem. Complete dissection is key when no crossing vessel is found so that the cause of obstruction can be clearly elucidated.
When a crossing vessel is found, the ureter is detached from the renal pelvis where they meet, the ends widened or spatulated to be wide open, and the ureter is reattached to the renal pelvis above, not under, the crossing vessel such that compression of the ureter will no longer occur. A stent will have already been placed in the ureter and kidney at a seperate setting in the case of Dr. Engel. This stent will remain in place for six weeks and will be removed in the office at that time. There are various ways to connect the ureter to the renal pelvis, and two different ways are demonstrated in the two videos below. When a crossing vessel is not found, the narrowed ureteropelvic junction (UPJ) is excised, the ends made wide, and again the ureter is reattached to the renal pelvis in a wide open fashion.
Warning, the video below represents an actual procedure – Content is graphic
Right Sided Robotic Pyeloplasty
Left Sided Robotic Pyeloplasty
Recovery after Robotic Pyeloplasty
Patients will typically be in the hospital for two days. Patients will feel fully recovered in two weeks, and will usually feel better each day. Vomiting or fevers are never to be ignored, and would always necessitate a trip to the George Washington Emergency room to be evaluated. All patients undergoing kidney surgery must know that there is always a very small risk that a nephrectomy will be required, a very small risk of restricturing or narrowing of the UPJ after surgery, as well as the usual risks of pain, infection and bleeding. Of course, with all abdominal surgery, there is a very small risk of inadvertent bowel or vascular injury.