Navigating the difficult robotic assisted pyeloplasty

Abstract

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.

Figure 1

Standard port placement for RAP. 8 mm robotic ports are placed in the upper and lower quadrant midclavicular lines. The 12 mm camera port is placed near the umbilicus. A 12 mm assistant port is placed in the suprapubic midline (circle). In right-sided cases, a midaxillary 5 mm port (arrow) may be needed for liver retraction. In obese patients, the assistant port may need to be moved to the subxiphoid region (square) or the midline (triangle) (assuming that the robotic ports have been moved laterally). (Figure adapted from [5] with permissions from the puplisher).

Figure 2

Robot docking for RAP. The patient's legs are shifted toward the operating surgeon, and the robot is brought in perpendicular to the room. This creates a 60 degree angle with the patient's spine and helps instrument mobility in the upper quadrants. (Figure adapted from [5] with permissions from the publisher.)