Outcome analysis of robotic pyeloplasty: a large single-centre experience

Role of buccal mucosa graft ureteroplasty in the surgical management of pyeloplasty failure

Objective

Secondary pyeloplasty for recurrent ureteropelvic junction obstructions may be a safe and feasible surgical option for patients. This study aimed to demonstrate outcomes of utilizing a non-transecting buccal mucosa graft ureteroplasty for management of recurrent ureteropelvic junction obstruction after prior failed pyeloplasty.

Methods

We performed a retrospective review of our Collaborative of Reconstructive Robotic Ureteral Surgery database for all consecutive patients who underwent buccal mucosa graft ureteroplasty between April 2012 and June 2022 for management of recurrent ureteropelvic junction obstructions after prior failed pyeloplasty. The primary outcome included surgical success which was defined as the absence of flank pain and no obstruction on imaging.

Results

Overall, ten patients were included in our analysis. The median stricture length was 2.5 (interquartile range [IQR] 1.8-4.0) cm. The median operative time was 230.5 (IQR 199.5-287.0) min and median estimated blood loss was 50.0 (IQR 28.8-102.5) mL. At a median follow-up of 10.3 (IQR 6.2-14.8) months, 80% of patients were surgically successful and there were no major (Clavien-Dindo Grade>2) complications.

Conclusion

Buccal mucosa graft ureteroplasty is a valuable non-transecting surgical option for patients with recurrent ureteropelvic junction obstructions who failed prior pyeloplasty and has comparable outcomes to the literature regarding standard transecting techniques.

Robotic-assisted laparoscopic pyeloplasty for the treatment of ureteropelvic junction obstruction - How should success be determined?

BACKGROUND

Ureteropelvic junction obstruction (UPJO) is characterised by stenosis of the ureteral lumen at the level of the renal pelvis and proximal ureter. At Haukeland University Hospital, robotic-assisted laparoscopic pyeloplasty (RLP) for UPJO has been performed since 2014. The aim of this study was to evaluate the results of the treatment and consider what determines treatment success.

MATERIALS AND METHODS

Retrospective review was performed of consecutive patients undergoing RLP between 2014-2022. Outcomes of interest included symptom relief, complication rates and renographic findings at follow-up. Treatment success was defined in terms of symptom improvement and/or improvement as well as relief of obstruction on renography.

RESULTS

In total, 95 RLPs were performed in 54 women and 41 men, with a mean age of 40 years (IQR: 21-58). Flank pain was the most frequent presenting complaint (n = 81, 85%) followed by infection (n = 33, 35%). More than one indication for surgery was present in 1/3 of the patients. Urodynamic relevant obstruction on renography was found in 62 patients (65%) preoperatively. Mean operative time was 123 minutes (range 60-270). Two patients experienced minor intraoperative complications. At three months follow-up, 91% of patients had symptom relief, and no obstruction on renography was recorded in 64%. There was no significant association between improvement in symptoms and renography findings at follow-up, p = 1.

CONCLUSIONS

RLP can deliver a high success rate in terms of symptom relief and few complications. There was no association between renography findings and symptom relief at follow-up. Success after surgery should be determined by symptom relief rather than renography findings.

[COMPARING LAPAROSCOPIC AND ROBOT-ASSISTED PYELOPLASTY FOR URETERO-PELVIC JUNCTION OBSTRUCTION: INITIAL EXPERIENCE FROM A SINGLE CENTER]

(Objective) To compare the initial results of robot-assisted laparoscopic pyeloplasty (RALP) and laparoscopic pyeloplasty (LP) for uretero-pelvic junction obstruction (UPJO). (Methods) Between April 2008 to October 2021, we identified 104 cases of UPJO where LP was performed and 18 cases where RALP was performed at our hospital. We retrospectively analyzed their perioperative outcomes. Furthermore, we recorded the operative times for each cases of LP and RALP. (Results) The median operative time for RALP was 141 minutes, which was significantly shorter than that for LP (204 minutes). No patient in the RALP group demonstrated any Clavien-Dindo complications (≥grade 3). During the observation period, improvement of symptoms was observed in all cases. The median suturing time in RALP was 38 minutes. Compared with the last 20 cases of LP, the time to expose the uretero-pelvic junction, the time of renal pelvis incision, and suturing time were significantly shorter in RALP. In addition, the console and suturing times were stable since the initial stage. In cases with a high grade of hydronephrosis, there was a large variation in the time to expose the uretero-pelvic junction and suture the renal pelvis and ureter in LP; however, this variation was smaller in RALP. (Conclusion) At our hospital, RALP for UPJO is considered to be a safe procedure. In the future, it is necessary to consider the long-term results and effectiveness of RALP.

A Comparison Between Laparoscopic and Robot-Assisted Laparoscopic Pyeloplasty in Patients with Ureteropelvic Junction Obstruction

Background

The aim of this study is to compare the results of laparoscopic pyeloplasty and robot-assisted laparoscopic pyeloplasty in patients with ureteropelvic junction obstruction.

Methods

Between March 2008 and May 2019, the patients who underwent retroperitoneal laparoscopic or robotic-assisted laparoscopic pyeloplasty in our institution were retrospectively reviewed.

Results

Thirteen patients underwent laparoscopically, and 12 patients underwent robotic surgery. The significant difference was found in median operative time between laparoscopic group (296 minutes) and robotic group (199 minutes) (P = 0.001). The median time for drain removal in laparoscopic group was longer than robotic group (3 vs. 2 days, respectively, P = 0.029).

Conclusion

Laparoscopic and robot-assisted laparoscopic pyeloplasty is safe and excellent success rates in patients with ureteropelvic junction obstruction. However, our experience study suggested that robotic surgery improves a total operative time, decreases drain removal time and less intraoperative blood loss than laparoscopic approach.

Are robots the future? A case for robotic pyeloplasty as the gold standard treatment in ureteropelvic junction obstruction

PURPOSE OF REVIEW

Robotic pyeloplasty is still a relatively novel procedure. Clinically, early studies have shown high success rates, decreased complication rates, decreased length of hospital stay, and better cosmetic results. This goal of this article is to argue for the use of robotic pyeloplasty as the gold standard of ureteropelvic junction obstruction (UPJO) treatment. Results of studies that have compared robotic pyeloplasty with other procedures currently used are reviewed.

RECENT FINDINGS

Our study, a comprehensive review of published outcomes of robotic pyeloplasty and alternative therapies, consisted of 666 pediatric patients and 653 adult patients. Our review coincided with the previously established studies that robotic pyeloplasty shows equivalent surgical success rates as previous standard of care treatments. Open pyeloplasty has fallen out of favor as standard of care due to the increased length of hospital stay, increased adverse events, and the undesirable aesthetics.

SUMMARY

The use of robotic pyeloplasty has shown to have clinical outcomes that are consistent with other intervention for UPJO, with a potential decrease in length of stay and morbidity. More work has to be done to develop ways to decrease cost of the robot to help establish it as the gold standard for UPJO treatment.

Retroperitoneal robotic-assisted laparoscopic pyeloplasty: A 10 year experience in a single institution

Introduction Pelvi-ureteric junction (PUJ) obstruction was traditionally treated with open pyeloplasty. In recent decades the development of minimally invasive techniques; including laparoscopic and later robotic surgery, has transformed treatment. The transperitoneal approach has most commonly been undertaken with few institutions reporting outcomes of the retroperitoneal approach. We report our 10 year experience of retroperitoneal robotic-assisted laparoscopic pyeloplasty (R-RALP). Methods A prospective database of 160 patients undergoing RALP between February 2010 and November 2019 was analysed. Data was recorded on demographics, operative details, complications and success rate. Success was determined as symptomatic improvement and/or an unobstructed renogram. Results 152 cases (95.0%) were performed using a retroperitoneal approach and 8 (5.0%) transperitoneal. Mean age was 45.317.4 years. Mean operating time was 139.445.6 minutes. A surgical drain was placed in 57 (71.3%) of the first 80 cases and 15 (18.8%) of the second 80 cases. Median hospital stay was 1 night (range 1-27). One case was converted to open pyeloplasty due to dense inflammatory tissue and one to robotic-assisted nephrectomy due to severe adhesions around the PUJ. There were no blood transfusions. There were 6 major (>grade 2 Clavien-Dindo) post-operative complications in 4 patients (2.5%). Two (1.3%) grade 3a complications: urine leak and pain after stent removal requiring nephrostomy. Three (1.9%) grade 3b complications: migrated stent requiring ureteroscopy, perirenal haematoma requiring open evacuation and stent re-insertion. One (0.6%) grade 4 complication requiring ventilatory support on intensive care. 18 patients received follow-up at an alternative hospital and 13 were lost to follow-up. Of the remaining cases 94.5% were successful. Conclusions R-RALP is a safe and effective treatment for PUJ obstruction allowing predictably rapid discharge from hospital without the need for a routine surgical drain. To our knowledge our study represents the largest single institution experience on RALP using a retroperitoneal approach.

Ureter-first Approach and Reduction of Pelvis: Standardizing Handling of Ureteropelvic Junction During Pyeloplasty

OBJECTIVE

To present our "ureter-first" approach as a standardized step-wise incision-making technique to deal with all types of uretero-pelvic junction (UPJ) anatomy during pyeloplasty. Pyeloplasty is a common surgery performed for UPJ obstruction, with Anderson-Hynes' pyeloplasty being the commonest. However, there is great variability in handling UPJ and incision-making among the surgeons with no detailed standardized description that can be followed in all cases, notwithstanding broad descriptions of incision lines. We underscore this aspect of pyeloplasty and present our universal technique with a goal to minimize surgical errors.

METHODS

A standardized step-by-step handling of UPJ and sequential incision-making was developed for pyeloplasty. It avoids unwarranted loss of any pelvis tissue before confirming individual UPJ anatomy, emphasizes preservation of lower lip of pelvis and minimizes tension on anastomosis. This standardized technique was uniformly used in all cases over 5 years. The peri-operative and functional outcome results are presented.

RESULTS

Fifty-one consecutive cases were done using ureter-first approach. UPJ was >1 cm in eight cases. Three of these had UPJ >2 cm. Eight other cases had a low-insertion below level of kidney while three had high insertion of ureter. There were no cases which were deemed to be done under tension or unsatisfactory repair by the surgeon. There were no failures requiring any kind of redo repair at mean follow up of 39 months.

CONCLUSION

A uniform standardized approach saves the surgeon from unwarranted or wrongly designed incisions on the pelvis and thus has the potential to reduce surgical mistakes.

Modified Laparoscopic and Robotic Flap Pyeloplasty for Recurrent Ureteropelvic Junction Obstruction with a Long Proximal Ureteral Stricture: The "Wishbone" Anastomosis and the "Ureteral Plate" Technique

OBJECTIVES

The aim of the study was to present our modified flap pyeloplasty techniques for recurrent ureteropelvic junction obstruction (UPJO) with a long proximal ureteral stricture and compare outcomes of laparoscopic and robotic procedures.

MATERIALS AND METHODS

Between March 2018 and January 2020, 21 patients underwent modified laparoscopic or robotic flap pyeloplasty for recurrent UPJO with a long proximal ureteral stricture. Our surgical modifications included the "wishbone" anastomosis and "ureteral plate" technique. Demographic, perioperative, and follow-up data were recorded and compared retrospectively between the groups. Success was defined as subjective pain alleviation and hydronephrosis improvement.

RESULTS

Thirteen modified laparoscopic flap pyeloplasty (mLFP) and 8 modified robotic flap pyeloplasty (mRFP) were performed successfully without conversion. mRFP tended to have shorter overall operative time (142.4 vs. 179.1 min, p = 0.122) and anastomosis time (43.1 vs. 61.0 min, p = 0.093) than mLFP. No difference was found in estimated blood loss (p = 0.723) and pararenal draining time (p = 0.175) between the groups. The mean postoperative hospital stay of mRFP was significantly shorter than that of mLFP (5.0 vs. 8.2 days, p = 0.015). No major complications occurred. During the mean follow-up of 17.9 months, the overall success rate was 90.5%, and there was no significant difference between 2 groups.

CONCLUSIONS

The modified flap pyeloplasty could be considered a practical and effective treatment option with a high success rate for recurrent UPJO with a long proximal ureteral stricture, and the robotic procedures showed advantages of higher efficiency and faster recovery.

Real-time navigation by three-dimensional virtual reconstruction models in robot-assisted laparoscopic pyeloplasty for ureteropelvic junction obstruction: our initial experience

Background

The aim of this study was to evaluate the effectiveness and safety of real-time surgical navigation by three-dimensional (3D) virtual reconstruction models in robot-assisted laparoscopic pyeloplasty (RALP).

Methods

Between November 2018 and January 2020, 38 patients with ureteropelvic junction obstruction (UPJO) who underwent RALP were retrospectively enrolled. The operations were assisted in real time by 3D models in 16 patients, while 22 patients underwent surgery without navigation. Based on whether patients had a prior intervention history, crossing vessels or congenital deformities, we further divided them into the “complicated UPJO” cohort and the “regular UPJO” cohort for subgroup analysis. The demographic characteristics, intraoperative parameters, perioperative data and follow-up data were recorded and compared between the groups.

Results

All of the procedures were successfully performed without open or laparoscopic conversion. The mean dissection time to the UPJ was shorter in the navigation group than in the non-navigation group, both in the whole cohort (15.3 vs. 24.8 min, P=0.011) and in the complicated cohort (15.4 vs. 27.5 min, P=0.004), while there was no significant difference in the regular cohort. The overall operative time and estimated blood loss in the navigation group tended to be less, although the difference was not statistically significant. No difference in anastomosis time, postoperative hospital stay or complications was noted between the two groups in either cohort. At a mean follow-up of 11.2 months, the overall success rate was 94.7% (36/38), and there was no significant difference between the two groups.

Conclusions

Real-time navigation by 3D virtual reconstruction models might be helpful to improve surgical efficiency and safety of RALP by facilitating the dissection around the UPJ, especially for cases of complicated UPJO. However, the prospective study with larger sample size is further needed to confirm the results.

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.

The robot-assisted ureteral reconstruction in adult: A narrative review on the surgical techniques and contemporary outcomes

Despite the rapid increase in the use of robotic surgery in urology, the majority of ureteric reconstruction procedures are still performed using laparoscopic or open approaches. This is primarily due to uncertainty regarding the advantages of robotic approaches over conventional ones, and the unique difficulty in identifying the specific area of interest due to the lack of tactile feedback from the current robotic systems. However, with the potential benefits of minimal invasiveness, several pioneering reports have been published on robotic surgery in urology. By reviewing the literature on this topic, we aimed to summarize the techniques, considerations, and consistent findings regarding robotic ureteral reconstruction in adults. Robotic applications for ureteral surgery have been primarily reported for pediatric urology, especially in the context of relieving a congenital obstruction in the ureteral pelvic junction. However, contemporary studies have also consistently demonstrated that robotic surgery could be a reliable option for malignant, iatrogenic, and traumatic conditions, which generally occur in adult patients. Nevertheless, the lack of comparative studies on heterogeneous hosts and disease conditions make it difficult to determine the benefit of the robotic approach over the conventional approach in the general population; thus, qualified prospective trials are needed for wider acceptance. However, contemporary reports have demonstrated that the robotic approach could be an alternative option for ureteral construction, even in the absence of haptic feedback, which can be compensated by various surgical techniques and enhanced three-dimensional visualization.

Single-Port Robot-Assisted Dismembered Pyeloplasty With Mini-Pfannenstiel or Peri-Umbilical Access: Initial Experience in a Single Center

OBJECTIVE

To assess the feasibility and describe the surgical technique for single-port robotic-assisted laparoscopic pyeloplasty using the new da Vinci SP surgical platform (Intuitive Surgical Inc., Sunnyvale, CA), and to describe the approach through a mini-pfannenstiel incision.

METHODS

Data from a prospectively maintained single-institution database on all patients undergoing single-port robotic-assisted pyeloplasty between November 2018 and November 2019 were reviewed. Pyeloplasty was performed with the da Vinci SP system through a pure single site approach (except for the first patient). The initial procedures were performed through a midline incision and the technique evolved to a mini-pfannenstiel incision. Patient demographics, intraoperative data, post-operative data and surgical outcomes were collected.

RESULTS

Overall, 10 patients were included and underwent the procedure without intraoperative complications or conversion to an alternate approach. The patients' ages ranged between 11 and 75 years. Mean operative time was 166 minutes (interquartile range [IQR] 146-181) and EBL was minimal. Pfannenstiel incision was performed for 6 patients and 4 patients had a vertical midline incision. The only complication recorded was a postoperative urinary tract infection treated with antibiotics. The median postoperative hospital stay was 21 hours (7-24). Postoperative pain management after discharge was managed exclusively with non-opioid medication. Overall success rate defined as the absence of pain and renal obstruction on post-operative imaging at 3 months after surgery was 100%.

CONCLUSION

Single-port robotic-assisted laparoscopic pyeloplasty is a safe and feasible procedure through a mini-pfannenstiel incision.

Comparison of open, laparoscopic and robot-assisted pyeloplasty for pelviureteric junction obstruction in adult patients

Ureteropelvic junction obstruction (UPJO) is a frequently found congenital abnormality of the upper urinary tract treated with pyeloplasty. We hereby report a study to compare open pyeloplasty (OP), laparoscopic pyeloplasty (LP) and robotic assisted pyeloplasty (RAP) for UPJO in terms of functional and perioperative outcomes. 102 patients who underwent Anderson-Hynes dismembered pyeloplasty for UPJO were divided into three groups based on type of surgical techniques utilized as follows: OP (Group A; n = 34), LP (Group B; n = 34), and RAP (Group C; n = 34). Preoperative, intraoperative and postoperative data were recorded. The mean operative time was significantly more in the Group B (187.76 min) than the Group A (132.06 ± 30.1 min) and Group C (136.76 ± 25.1 min) (p < .001). Mean blood loss was more in OP group 86.47 ± 29. 35 ml versus 42.94 ± 20. 77 ml in RAP and 45.59 ± 20. 3 ml in the LP group (p < .001). The LP was found to be much tiring. Mean surgeon fatigue index (SFI) calculated was 7 ± 1.1 in the LP group compared to 4.12 ± 1.1 in RAP group and the difference was statistically significant (p< .001). Average VAS score in the first 2 days postoperatively was 6.66±1.58 in the OP group compared to 4.29 ± 1.16 in RAP group and 4.29 ± 1.31 in the LP group (p < 0.001). Pyeloplasty has a similar success rate and efficacy irrespective of the technique utilized. RAP improves the surgeons QOL (quality of life) and the fatigue scores, which is useful for surgeon longevity. RAP has become widely favorite and can be considered the approach of choice in the management of UPJO wherever infrastructure and finances allow.

Robot-assisted urological surgery in the Middle East: Where are we and how far can we go?

Objectives: To evaluate robot-assisted surgery (RAS) in Urology in the Middle East, and its status and future perspectives.

Methods: A Medical Literature Analysis and Retrieval System Online (MEDLINE) search was performed using the following keywords: ‘robotics’, ‘robot-assisted surgery’, ‘laparoscopy’, at first with each specific procedure name, such as radical cystectomy, followed by ‘Middle East’ and country names. All abstracts and articles in English that adhered to the scope of the current issue were selected, giving special consideration to relevant landmark articles and those describing trends and the future of RAS in Urology.

Results: Only a few index case reports characterised RAS in the Middle East. The Middle East possess only 1% of the da Vinci® Surgical Systems (Intuitive Surgical Inc., Sunnyvale, CA, USA) installed worldwide, including 19 in Saudi Arabia; six in Qatar; two in each of Kuwait and Lebanon; three in the United Arab Emirates; and only one in Egypt. The total number of RAS performed in the Middle East is low compared to Europe and the USA. Many countries in the Middle East still lack surgical robots despite having the expertise and appropriate caseload, whilst others seem not to utilise the surgical robot at a suitable rate, as reflected by the sparse number of operated cases and outgoing publications. There are major differences in RAS availability, usage, and perception according to the geographical place of practice and acceptance of robots by surgeons and patients.

Conclusion: RAS in Urology continues to grow in the Middle East, with increasing caseloads and diversity of operated cases. Acceptance of robots by Middle East surgeons is significantly increasing.

Abbreviations: 3D: three-dimensional; KSA: Kingdom Saudi Arabia;MIS: minimally invasive surgery; RAA: robot-assisted adrenalectomy; RAP: robot-assisted pyeloplasty; (O)(RA)PN: (open) (robot-assisted) partial nephrectomy; RAS: robot-assisted surgery; (O)(RA)RC: (open) (robot-assisted) radical cystectomy; (RA)RP: (robot-assisted) radical prostatectomy; SAUC: Sabah Al-Ahmad Urology Center

Learning robotic pyeloplasty without simulators: an assessment of the learning curve in the early robotic era

OBJECTIVE

To analyze our experience and learning curve for robotic pyeloplasty during this robotic procedure.

METHODS

Ninety-nine patients underwent 100 consecutive procedures. Cases were divided into 4 groups of 25 consecutive procedures to analyze the learning curve.

RESULTS

The median anastomosis times were 50.0, 36.8, 34.2 and 29.0 minutes (p=0.137) in the sequential groups, respectively. The median operative times were 144.6, 119.2, 114.5 and 94.6 minutes, with a significant difference between groups 1 and 2 (p=0.015), 1 and 3 (p=0.002), 1 and 4 (p<0.001) and 2 and 4 (p=0.022). The mean hospital stay was 7.08, 4.76, 4.88 and 4.20 days, with a difference between groups 1 and 2 (p<0.001), 1 and 3 (p<0.001) and 1 and 4 (p<0.001). Clinical and radiological improvements were observed in 98.9% of patients. One patient presented with recurrent obstruction.

CONCLUSIONS

Our results demonstrate a high success rate with low complication rates. A significant decrease in hospital stay and surgical time was evident after 25 cases.

Robotic Ureteral Reconstruction in the Pediatric Population

Robot-assisted laparoscopic (RAL) surgery is a safe, minimally invasive technique that has become more widely used in pediatric urology over recent decades. With several advantages over standard laparoscopy, robotic surgery is particularly well-suited to reconstructive surgery involving delicate structures like the ureter. A robotic approach provides excellent access to and visualization of the ureter at all levels. Common applications include upper ureteral reconstruction (e.g., pyeloplasty, ureteropelvic junction polypectomy, ureterocalicostomy, and high uretero-ureterostomy in duplex systems), mid-ureteral reconstruction (e.g., mid uretero-ureterostomy for stricture or polyp), and lower ureteral reconstruction (e.g., ureteral reimplantation and lower ureter-ureterostomy in duplex systems). Herein, we describe each of these robotic procedures in detail.

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

The management of complex pelvic-ureteric junction obstruction (PUJO) is challenging. The traditional open surgical approach used large incisions with prolonged post-operative recovery. Laparoscopic reconstruction in complex PUJO requires surgical expertise and is challenging to master. Robotic assistance has provided a viable minimally invasive alternative replicating the open surgical approach for such complex cases. In the present study, we evaluated the feasibility and success of robot-assisted reconstructive procedures in such situations.

Robot-assisted laparoscopic pyeloplasty: a single-centre experience

BACKGROUND

Ureteropelvic junction obstruction (UPJO) is characterised by an obstruction compromising the passage of urine from the renal pelvis into the ureter, and can be corrected by Robot-Assisted Laparoscopic Pyeloplasty (RALP). We aimed to evaluate the surgical outcomes of RALP, and examine the rates of true pain resolution following the procedure.

METHODS

We retrospectively explored the records of all patients who underwent RALP between April 2005 and January 2017. Measures of success were defined as the prevention of deterioration in split renal function and resolution of obstruction, and the resolution or improvement in subjective pain levels.

RESULTS

83 patients were included in this series. Mean patient age was 40.8 years. 38 patients had a left sided RALP, whilst 45 underwent RALP on the right. Crossing vessels were identified in 53.0% of patients. Mean operative time was 148.0 min. 68 patients had pain as their presenting feature. Following RALP, the pain resolved in 69.2% (n = 47), improved in 26.5% (n = 18), and remained the same in 4.4% (n = 3). 11.8% (n = 8) of patients required referral to other specialities for pain management. Success from a radiological perspective of cleared obstruction and arrest of deteriorating renal function was 97.6%.

CONCLUSIONS

Our individual outcomes demonstrate a high success rate regarding resolution of obstruction and preventing deterioration in renal function. We also report that a number of patients, who despite meeting the radiological criteria to undergo RALP, had alternate underlying causes for their pain symptoms. For this reason, we propose that the primary measure of success for RALP should be based on renal function and radiological outcomes, rather than the outcomes relating to pain. Both surgeons and patients should be aware that whilst RALP is a highly successful procedure, persistence of pain may be due to overlapping clinical conditions which can be managed by a multidisciplinary approach.

Bladder and Ureteral Dysfunction Leading to Hydronephrosis and Hydroureteronephrosis in Adults

Chronic non-stone-related hydronephrosis from supravesical or bladder dysfunction in adults is often detected incidentally. This study aims to review the literature regarding supravesical obstruction or bladder dysfunction leading to bilateral hydronephrosis in adults and to develop an algorithm to identify patients at risk of renal failure. Cross-sectional studies, retrospective and prospective cohorts, clinical trials, and systematic reviews from 1980 to 2017 were included. From 8115 articles screened, 39 met the inclusion criteria. Despite the lack of studies addressing this issue, this review brings up a rational evidence-based algorithm to diagnose and manage adults with bilateral hydronephrosis due to supravesical or bladder disease or dysfunction.

Is One Early Renographic Follow-Up Adequate to Measure the Success of Robotic Pyeloplasty?

PURPOSE

Diuretic renography (DRG) is commonly used to diagnose ureteropelvic junction obstruction (UPJO) and to evaluate the success of surgical repair (pyeloplasty). Duration, frequency, and interpretation of renographic follow-ups are still under dispute.

METHODS

We retrospectively reviewed 94 consecutive patients diagnosed with UPJO who underwent a minimally invasive, robotically assisted laparoscopic pyeloplasty at our institution between January 2009 and September 2015. DRG was carried out preoperatively and again routinely 4 to 6 weeks postoperatively the day after stent removal (early DRG). Patients were scheduled for repeat (late) DRG and follow-up examinations, including clinical status and ultrasonography.

RESULTS

Nineteen patients with missing preoperative DRG were excluded from the study; the remaining 75 patients were eligible for statistical evaluation. At follow-up, 98.7% reported no or only very mild and rare symptoms. On early DRG, 52.5% had T_1/2 ≤ 10 min (unobstructed), 39.3% had T_1/2 between 10 and 20 minutes (equivocal), and 8.2% had T_1/2 ≤ 20 minutes (obstructed). At late follow-up, the DRG results had improved to 80.8% unobstructed with 19.2% remaining equivocal, and no patients were obstructed; thus, the overall success rate was 80.8%. There was only one patient who worsened from unobstructed to equivocal from early to late DRG assessment.

CONCLUSION

In case of complete symptom resolution, a nonobstructive diuretic half-time of ≤10 minutes on early DRG following stent removal suggests that further routine renographic follow-up is unnecessary. Patients with an equivocal early DRG (T_1/2 between 10 and 20 minutes) require further scintigraphic follow-up, as they have a 42.1% chance of staying equivocal.

Robot-assisted Surgery for Benign Ureteral Strictures: Experience and Outcomes from Four Tertiary Care Institutions

BACKGROUND

Minimally invasive treatment of benign ureteral strictures is still challenging because of its technical complexity. In this context, robot-assisted surgery may overcome the limits of the laparoscopic approach.

OBJECTIVE

To evaluate outcomes for robotic ureteral repair in a multi-institutional cohort of patients treated for ureteropelvic junction obstruction and ureteral stricture (US) at four tertiary referral centres.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective study reports data for 183 patients treated with standard robot-assisted pyeloplasty (PYP) and robotic uretero-ureterostomy (UUY) at four high-volume centres from January 2006 to September 2014.

SURGICAL PROCEDURE

Robotic PYP and robot-assisted UUY were performed according to previously reported surgical techniques.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Preoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed.

RESULTS AND LIMITATIONS

No robot-assisted UUY cases required surgical conversion, while 2.8% of PYP cases were not completed robotically. The median operative time was 120 and 150min for robot-assisted PYP and robot-assisted UUY, respectively. No intraoperative complications were reported. The overall complication rate for all procedures was 11% (n=20) and complications were mostly of low grade. The high-grade complication rate was 2.2% (n=4). At median follow-up of 24 mo, the overall success rate was >90% for both procedures. The study limitations include its retrospective nature and the heterogeneity of the study population.

CONCLUSIONS

Robotic surgery for benign US is safe and effective, with limited risk of high-grade complications and good intermediate-term results.

PATIENT SUMMARY

In this study we review the use of robotic surgery at four different tertiary care centres in the treatment of patients affected by benign ureteral strictures. Our results demonstrate that robotic surgery is a safe alternative to the standard open approach in the treatment of ureteral strictures.

Outcomes of robot-assisted laparoscopic transperitoneal pyeloplasty procedures: a series of 18 patients

OBJECTIVE

We evaluated outcomes of our robot-assisted laparoscopic transperitoneal pyeloplasty (RALP) procedures.

MATERIAL AND METHODS

Between July 2011 and March 2014, 18 RALP procedures were performed at our instutition. Ureteropelvic junction obstruction (UPJO) diagnosis was made based on clinical presentation and intravenous urography. All patients underwent basal and diuretic isotopic renography to evaluate the degree of obstruction and impaired renal function. Anderson-Hynes dismembered pyeloplasty technique was used with a transperitoneal approach by using the da Vinci-S 4-arm surgical robot. Outcomes were assessed retrospectively.

RESULTS

Mean patient age was 31.3±11.7 (13-62) years. Male: female ratio was 9: 9. All procedures were primary surgeries. Of 18 patients, 10 (55.5%) had a crossing vessel and 8 (44.5%) had intrinsic obstruction. Mean operative time was 150.4±17.2 (115-185) minutes. Mean anastomosis time was 21.4±5.5 (10-33) minutes. Mean blood loss during the operation was 33.6±17.3 (10-60) cc. Mean hospital stay was 2.6±1.0 (1-6) days. No conversion to open surgery was required. No intraoperative and perioperative (0-30 days) complication occurred. Readmission rate during perioperative period was 0%. Median follow-up was 16.6±10.3 (3-35) months. Postoperative intravenous urography and renography showed improved results in all cases.

CONCLUSION

Due to our experience, RALP is a safe and feasible minimally invasive approach in patients with UPJO with excellent surgical and functional outcomes.

Comparison of surgical and functional outcomes of open, laparoscopic and robotic pyeloplasty for the treatment of ureteropelvic junction obstruction

OBJECTIVE

To compare the surgical and functional outcomes of open, laparoscopic and robotic dismembered pyeloplasty for the treatment of patients with ureteropelvic junction obstruction (UPJO).

MATERIAL AND METHODS

Between 2007 and 2012, a total of 56 patients underwent conventional open (Group 1; n=25), laparoscopic (Group 2; n=16), and robotic (Group 3; n=15) dismembered pyeloplasty operations. Preoperative evaluation was performed using urinalysis, urine culture, blood biochemistry, urinary ultra-sound, intravenous pyelogram (IVP) (optional) and Mercaptoacetyltriglycine (MAG-3) renal scan. The mean operation time, estimated blood loss, drain removal time, narcotic analgesic requirements, length of hospital stay and functional outcomes were compared among groups. Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) v. 20 (IBM, Armonk, NY, USA) software, and statistically significant differences were determined using a p value <0.05.

RESULTS

The mean age of the patients was 30 years in Group 1, 34.3 years in Group 2 and 32.9 years in Group 3. The mean operation time was 127, 130 and 114 min (p=0.32), and the estimated blood loss was 105, 31 and 28 mL, respectively (p=0.001). The drain was removed after 4.36 (±1.3), 2.33 (±0.6) and 1.8 (±0.6) days after surgery (p<0.001), and the mean hospital stay was 4.14 (±1.8), 2.8 (±0.75) and 2 (±1) days, respectively (p<0.001). Narcotic analgesic requirement was significantly higher in Group 1 compared with Groups 2 and 3 (p=0.02). The radiographic and symptomatic success rates were 96% in Group 1, 93.75% in Group 2 and 93.3% in Group 3.

CONCLUSION

Laparoscopic and robotic pyeloplasty are feasible, effective, reliable and minimally invasive treatment approaches for the treatment of UPJO as compared with open dismembered pyeloplasty.

An up-to-date overview of minimally invasive treatment methods in ureteropelvic junction obstruction

Introduction

Over the last two decades, minimally invasive treatment options for ureteropelvic junction obstruction have been developed and are bcoming more popular. Multiple series of laparoscopic pyeloplasty have demonstrated high success rates and low perioperative morbidity in pediatric and adult populations, for both the transperitoneal and retroperitoneal approaches. In this review, we aimed to analyze the current status of minimally invasive therapy of ureteropelvic junction obstruction.

Material and methods

A PubMed database search was conducted to examine minimally invasive treatments of ureteropelvic junction obstruction.

Results

A large number of cases have been reported for adult patients, confirming that robotic pyeloplasty represents a viable option for either primary or secondary repair. Comparative studies demonstrate similar success and complication rates between minimally invasive and open pyeloplasty in both the adult and pediatric populations. A clear advantage, in terms of hospital stay, of minimally invasive over open pyeloplasty was observed only in the adult population.

Conclusions

Studies have shown that minimally invasive pyeloplasty techniques are a safe, effective, and feasible in adult and pediatric populations.

Defining the pros and cons of open, conventional laparoscopy, and robot-assisted pyeloplasty in a developing nation

Introduction. Congenital pelviureteric junction obstruction (PUJO) is one of the most common causes of hydronephrosis. Historically, open dismembered pyeloplasty has been considered the gold standard intervention for correcting PUJO. The aim of this study was to compare the surgical and functional outcomes of three different approaches, namely, open, conventional laparoscopy, and robotic pyeloplasty. Material and Methods. 60 patients underwent minimally invasive pyeloplasty (30 conventional laparoscopies and 30 robotics) for congenital PUJO at a tertiary health center in India. Demographic, perioperative, and postoperative data were prospectively collected and analyzed. The data of these patients were retrospectively compared with another cohort of 30 patients who had undergone open pyeloplasty. Results. There was significant difference in operative time, time to drain removal, hospital stay, pain score, and complications rate between open and minimally invasive pyeloplasty (P < 0.05). SFI was considerably lesser in robotic as compared to conventional laparoscopy. The success rate in OP, CLP, and RP was 93.33, 96.67, and 96.67%. Conclusion. Robotic pyeloplasty is safe, effective, and feasible. It is associated with significantly lesser operative time, lesser blood loss, less pain, shorter hospital stay, and fewer complications. It is also associated with considerably lesser surgeon fatigue as compared to conventional laparoscopy pyeloplasty.

Trends in followup imaging after adult pyeloplasty

PURPOSE

Although success rates are reported to be high, radiographic followup after pyeloplasty to correct ureteropelvic junction obstruction varies in intensity and modality. We characterized postoperative care after pyeloplasty to identify imaging trends.

MATERIALS AND METHODS

Using the MarketScan® database we identified patients 17 to 65 years old treated with pyeloplasty from 2007 to 2010. Followup imaging was classified as functional (diuretic renogram or excretory urogram) and nonfunctional (ultrasound, computerized tomography or magnetic resonance imaging). The postoperative period was divided into intervals of less than 6, 6 to 12, 12 to 24, 24 to 36 and greater than 36 months. We excluded from study patients with less than 24 months of postoperative enrollment in MarketScan. Multivariate logistic regression was used to determine associations between demographic variables and imaging utilization patterns.

RESULTS

We identified 742 patients with a mean ± SD followup of 36.8 ± 3.7 months, of whom 65% underwent minimally invasive pyeloplasty. Of the patients 12% underwent no postoperative imaging. Within the first 6 months 554 patients (75%) underwent at least 1 imaging study and within the first 12 months 82% underwent at least 1 imaging study, which was most commonly functional. After 12 months 54% of patients underwent any imaging, which was most commonly nonfunctional. At least annual imaging was significantly associated with older age, female gender and longer hospital stay. Secondary procedures were required in 62 patients (8%).

CONCLUSIONS

After pyeloplasty in adulthood most patients undergo a functional imaging study within 6 months. However, after 1 year only half of patients undergo followup imaging. Variability and insufficient radiological followup may bias the belief of pyeloplasty success.

Robot-assisted and laparoscopic repair of ureteropelvic junction obstruction: a systematic review and meta-analysis

CONTEXT

Over the last two decades, minimally invasive treatment options for ureteropelvic junction obstruction (UPJO) have been developed and popularized.

OBJECTIVE

To critically analyze the current status of laparoscopic and robotic repair of UPJO.

EVIDENCE ACQUISITION

A systematic literature review was performed in November 2012 using PubMed. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria.

EVIDENCE SYNTHESIS

Multiple series of laparoscopic pyeloplasty have demonstrated high success rates and low perioperative morbidity in pediatric and adult populations, with both the transperitoneal and retroperitoneal approaches. Data on pediatric robot-assisted pyeloplasty are increasingly becoming available. A larger number of cases have also been reported for adult patients, confirming that robotic pyeloplasty represents a viable option for either primary or secondary repair. Robot-assisted redo pyeloplasty has been mostly described in the pediatric population. Different technical variations have been implemented with the aim of tailoring the procedure to each specific case. The type of stenting, retrograde versus antegrade, continues to be debated. Internal-external stenting as well as a stentless approach have been used, especially in the pediatric population. Comparative studies demonstrate similar success and complication rates between minimally invasive and open pyeloplasty in both the adult and pediatric setting. A clear advantage in terms of hospital stay for minimally invasive over open pyeloplasty was observed only in the adult population.

CONCLUSIONS

Laparoscopy represents an efficient and effective less invasive alternative to open pyeloplasty. Robotic pyeloplasty is likely to emerge as the new minimally invasive standard of care whenever robotic technology is available because its precise suturing and shorter learning curve represent unique attractive features. For both laparoscopy and robotics, the technique can be tailored to the specific case according to intraoperative findings and personal surgical experience.

Robotic versus conventional laparoscopic pyeloplasty: A single surgeon concurrent cohort review

Introduction:

The increasing availability of robotic devices has led to an increase in their use for procedures such as pyeloplasty, which have been conventionally performed laparoscopically or through open surgery. We perform both laparoscopic and robotic-assisted pyeloplasty routinely and have compared these techniques in a set of concurrent cohorts, operated by the same surgeon.

Materials and Methods:

A chart review was performed of all cases of Robot-assisted laparoscopic pyeloplasty (RALP) and conventional laparoscopic pyeloplasty (CLP) performed by a single surgeon, from September 2006 to July 2010. The choice of procedure depended upon the availability of the robot on the given day. A lateral transperitoneal approach was used in all cases. All anastomoses were stented antegrade. A diuretic renogram was obtained in all patients between six to twelve weeks after stent removal. Success was defined as a resolution of symptoms with non-obstructive outflow on the renogram.

Results:

Thirty patients underwent 31 laparoscopic pyeloplasties (20 RALPs and 11 CLPs), with one patient undergoing bilateral simultaneous robotic procedures. The robotic procedures were superior in terms of shorter operating time by 20 minutes on an average. Furthermore, 35% of the robotic procedures were performed in under 90 minutes, while the minimum time taken for laparoscopy was 110 minutes. All procedures in both cohorts were successful with no complications in either group. The surgeon recorded subjective ergonomic benefits with the use of the robot.

Conclusions:

Robotic assistance helps decrease the operative time for laparoscopic pyeloplasty. It seems ergonomically superior for the surgeon, allowing multiple procedures in the same list. These may be important benefits in busy centers.

Robotic Anderson-Hynes dismembered pyeloplasty: initial experience

INTRODUCTION

The introduction of the da Vinci(®) robotic system in 2000 has been a new step forward in the treatment of ureteropelvic junction obstruction (UPJO). The aim of this study was to analyse our initial experience with robot-assisted dismembered Anderson-Hynes pyeloplasty and to perform a bibliographic review on the topic.

PATIENTS AND METHODS

We performed 11 robot-assisted pyeloplasties between March 2007 and April 2011. UPJO diagnosis was made on clinical presentation and imaging techniques (CT scan and intravenous urography). All patients underwent basal and diuretic isotopic renograms to evaluate the degree of obstruction and impaired renal function. Median follow-up was 10 (range 1-26) months.

RESULTS

Mean patient age was 38.8 (range 23-62) years. There were six women (55%) and five men (45%). All cases were primary surgeries. In four patients the cause of UPJO was a crossing vessel; the other seven patients had intrinsic obstruction. One case was associated with extraction of a calyceal lithiasis. Mean operative time was 189.4 min (125-270 min). Average time from robotic arms docking was 116.5 (range 55-180) min. Average hospital stay was 4.18 (range 2-8) days. Conversion to open or laparoscopic surgery was not necessary in any case and there were no postoperative complications. Postoperative radiological evaluation and renograms showed good results in all cases.

CONCLUSIONS

Robotic surgery offers better ergonomics, enhanced three-dimensional (3D) vision and more precise movements, easing intracorporeal suturing.These advantages make robotic pyeloplasty a reproducible technique that combines the high success rates of open surgery and the benefits of laparoscopic surgery.

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.

Current trends in minimally invasive reconstructive urology

This paper is a systematic review of the current literature in minimally invasive reconstructive urological surgery. It focuses on the commonest reconstructive procedures in both the upper and lower urinary tracts including laparoscopic and robotic pyeloplasty for ureteropelvic junction obstruction, laparoscopic and robotic bladder diverticulectomy, laparoscopic and robotic partial cystectomy with urinary diversion, laparoscopic and robotic cystoplasty, repair of colovesical fistula, and, in urogynaecology, repair of vesicovaginal fistula. To evaluate the development, current status, feasibility, and safety of minimally invasive surgery (MIS) in reconstructive urology the literature on the topic was collated and reviewed.

Robot-assisted laparoscopic dismembered pyeloplasty for ureteropelvic junction obstruction: a multi-institutional experience

OBJECTIVE

To report a 6-year multi-institutional experience and outcomes with robot-assisted laparoscopic pyeloplasty (RLP) for the repair of ureteropelvic junction obstruction (UPJO).

PATIENTS AND METHODS

Between June 2002 and October 2008, 168 adult patients from 3 institutions underwent RLP for UPJO. A retrospective analysis of prospectively collected data were performed after institutional review board approval. Diagnosis was by intravenous urogram or computed tomography scan and diuretic renogram. All patients underwent RLP through a 4-port laparoscopic technique. Demographic, preoperative, operative, and postoperative endpoints for primary and secondary repair of UPJO were measured. Success was defined as a T½ of <20 minutes on diuretic renogram and symptom resolution. Pain resolution was assessed by subjective patient reports.

RESULTS

Of 168 patients, 147 (87.5%) had primary repairs and 21 (12.5%) had secondary repairs. Of the secondary repairs, 57% had a crossing vessel etiology. Mean operative time was 134.9 minutes, estimated blood loss was 49 mL, and length of stay was 1.5 days. Mean follow-up was 39 months. Overall, 97.6% of patients had a successful outcome, with a 6.6% overall complication rate.

CONCLUSIONS

To our knowledge, this review represents the largest multi-institutional experience of RLP with intermediate-term follow-up. RLP is a safe, efficacious, and viable option for either primary or secondary repair of UPJO with reproducible outcomes, a high success rate, and a low incidence of complications.

Robot-assisted urologic surgery in 2010 - Advancements and future outlook

Robotic surgery is a cutting edge and minimally invasive procedure, which has generated a great deal of excitement in the urologic community. While there has been much advancement in this emerging technology, it is safe to say that robotic urologic surgery holds tremendous potential for progress in the near future. Hence, it is paramount that urologists stay up-to-date regarding new developments in the realm of robotics with respect to novel applications, limitations and opportunities for incorporation into their practice. Robot-assisted surgery provides an enhanced 3D view, increased magnification of the surgical field, better manual dexterity, relatively bloodless field, elimination of surgeon's tremor, reduction in a surgeon's fatigue and mitigation of scattered light. All these factors translate into greater precision of surgical dissection, which is imperative in providing better intraoperative and postoperative outcomes. Pioneering work assessing the feasibility of robotic surgery in urology began in the early 2000's with robot-assisted radical prostatectomy and has since expanded to procedures such as robot-assisted radical cystectomy, robot-assisted partial nephrectomy, robot-assisted nephroureterectomy and robot-assisted pyeloplasty. A MEDLINE search was used to identify recent articles (within the last two years) and publications of specific importance, which highlighted the recent developments and future direction of robotics. This review will use the aforementioned urologic surgeries as vehicles to evaluate the current status and future role of robotics in the advancement of the field of urology.

Unilateral anomalies of kidney development: why is left not right?

Abnormal renal development results in congenital anomalies of the kidney and urinary tract. As many studies suggest that renal malformations are more often found on the left side, a meta-analysis was performed on the distribution of five different unilateral anomalies: multicystic dysplastic kidney, renal agenesis/aplasia, renal ectopia, pelviureteral junction obstruction, and non-obstructive non-refluxing megaureter. Of these anomalies, the left side was affected in 53%, 57%, 56.9%, 63.2%, and 62.5% of patients, respectively, significantly different when compared with an anticipated 50% of left-sided anomalies. An exception to this left-side predominance was found in females with combined genital anomalies and unilateral renal agenesis that commonly present on the right side. The exact mechanisms leading to these lateralizations remain to be determined but may involve vascular development, differential gene expression, or susceptibility to environmental factors such as hypoxia. This remains largely speculative, however, illustrating our limited knowledge of embryogenesis in general and nephrogenesis in particular.