Robotic laparoscopic pyeloplasty

Overview

Introduction: Laparoscopic pyeloplasty is one of the most demanding laparoscopic surgical procedure. The reason is the necessity of precise tissue preparation, spatulation of the ureter, resection of the pelvis and suturing of the anastomosis of the pelvis and ureter with rigid laparoscopic instruments. Robotic systems provide us with significant help, their disadvantage is however, that they are not available at all workplaces. New to the market are robotic laparoscopic instruments that are more affordable, combining advantages of conventional laparoscopy and robotics.

Case report: We present a robotic laparoscopic pyeloplasty in a 37-year-old patient with congenital hydronephrosis on the left side. The patient was primarily examined for renal colic, an acute non-contrast CT scan of the abdomen confirmed significant hydronephrosis, but no ureterolithiasis was found. The subsequent CT IVU examination confirmed a complex diagnosis of the collecting renal system: bilateral duplex pelvis, right ureter, left duplex ureter and hydronephrosis of the left lower moiety, likely caused by an aberrant vessel below the PU (pyeloureteral) junction. Dynamic renal scintigraphy showed cumulative retention of the radiopharmaceutical in the lower pole moietyof the left kidney, without response to diuretics in the monitored time with signs of obstruction in the PUJ (PU junction). The patient was indicated for laparoscopic pyeloplasty of the left lower moiety of the kidney. The operation was performed by a single surgeon with the assistance of Soloassist II robotic arm with voice control. For dissection, resection of the pelvis and spatulation of the ureter DEX scissors were used. To suture the posterior wall of the anastomosis of the ureter and pelvis we used Vycril 4.0 stitches, and for the anterior wall V-lock 4.0. To perform these continuous sutures we utilized the flexibility of the robotic DEX needleholder with seven degrees of freedom of movement. The ureteropelvic anastomosis was sutured over a DJ stent inserted retrogradely. The operation time was 140 minutes. The urinary catheter was removed on the 3rd postoperative day, the surgical drain a day after and the DJ-stent 6 weeks after the operation on an outpatient basis. Compared to the current robotic systems, both purchase and operating prices of the used robotised devices are many times lower. The purchase cost of the robotic laparoscopic system is 1.8 million Czech crowns (Kč) with the operating cost averaging 7,000 CZK per use of the instrument. While the purchase price for the Soloassist II robotic arm, depending on the equipment, is around 2 million Czech crowns (Kč).

Conclusion: Robotic laparoscopy enables precision with the possibility of using seven degrees of freedom of movement, maintaining tactile feedback and ergonomics (comfort) of the surgeon during operation. After a short practice, even in the hands of a less experienced laparoscopist, these instruments can improve surgical results, can reduce perioperative complications and operative time. Low acquisition and operating costs ensure an interesting future for robotic laparoscopy.

Keywords:

pyeloplasty – Robotic laparoscopy – congenital hydronephrosis – duplex renal collecting system.