Robotic Pyeloplasty Information
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A pyeloplasty is used for PUJ obstruction.
So what that is is patients have a renal pelvis so the kidney drains urine into something called the renal pelvis and then there's a thin tube called the ureter that takes that down to the bladder.
When you have a narrowing at the renal pelvis that obstructs the kidney and that's called PUJ obstruction.
Patients usually present with symptoms such as, it's very similar to kidney stones with severe pain. Sometimes it's incidentally found.
Traditionally this has been treated with a big open incision1 and it's quite a large incision right along the, the loin area and it's two to three month recovery, seven to 10 days in hospital.
I have been performing PUJ treatments in a minimally invasive method, so I've presented this nationally and internationally.2
For some patients we do it endoscopically through the eye of the penis.
We go up there with a little telescope, we use the holmium laser and incise the, the obstruction, put a balloon that stretches it up, puts, we put a stent in and leave that in for six weeks and then take the stent out.
That's called a laser endopyelotomy.
The risks of that are that you can get bleeding if there's some adjacent vessels there.
It's not very good if the blockage is very large but it's good for patients who have had failed treatment and patients that don't want to have any form of either surgery.
The success rates are slightly lower than with surgery, with open surgery, with a success rate of about 75% or so3.
But I presented this data internationally and we've been very happy with those outcomes.2
The other way of treating this is either via laparascopic or robot assisted method and I've been very fortunate to have our robot donated to our hospital.
I've presented the robotic pyleoplasty data and really I think it's transformed this condition.
Basically patients used to have small incisions made.
We have the robotic device that comes in and attaches, I unscrub, I sit at a console, I move my hand controls, as I move my hand controls the instrument inside the abdomen and replicate my hand movements.
We have gas pressure in the abdomen which creates space.
We actually have a third arm, a spare arm that I press the pedal on and it activates to retract the bowel.
So the narrow segment gets excised, the robotic arms have more degrees of movement than your wrist so we can move the instruments around.
We cut the narrow segment and then we can stitch it up. So we, we, the robot allows 10 times magnification.
It's a three dimensional view, it's like doing the operation with an operating microscope and we do a very, very accurate join.
So patients are usually out of hospital in about two days with this method but most importantly it's their recovery, they're back up and about in about a week or so as opposed to two to three months.
I also did this laparascopically but the instruments when you do it laparascopically and just open and close they don't rotate around and it's much harder4 to do a very accurate join.
So I believe that really robot assisted pyleoplasty should be the gold standard in patients with PUJ obstruction and certainly patients who have PUJ obstruction should at least be informed about this treatment option and consider this option.
So far we've had an excellent success rate with all our patients2 having complete relief of obstruction and really the literature shows the success rate is 95% plus5.
So previously I used to do a lot of endopyelotomies rather than the open incision but now patients tend to go for a robot assisted pyleoplasty with a higher success rate than endopyelotomy6 and they have the advantage of minimally invasive surgery.
Robotic Pyeloplasty Information
What is PUJ obstruction?
The kidney drains urine into a collecting area called the renal pelvis, which then narrows into a thin tube (the ureter) that carries urine down to the bladder. When there is a narrowing where the renal pelvis meets the ureter, urine cannot drain and the kidney is obstructed. This is called pelvi-ureteric junction (PUJ) obstruction.
Patients typically present with severe pain similar to a kidney stone, although PUJ obstruction is sometimes found incidentally on imaging.
Traditional open surgery
PUJ obstruction has traditionally been treated with a large open incision along the loin1, followed by seven to ten days in hospital and a two- to three-month recovery.
Laser endopyelotomy - endoscopic option
In selected patients, Dr Kooner can treat the obstruction endoscopically through the urethra. A small telescope is passed up to the renal pelvis; the holmium laser is used to incise the narrowing; a balloon is used to stretch the area open; and a stent is placed for six weeks to hold the opening while it heals.
This approach suits patients who have had failed previous treatment or who want to avoid surgery. The main risk is bleeding if nearby blood vessels are in the path of the incision, and it is less effective where the blockage is long. Success rates are lower than with surgical reconstruction - around 75%3 - although Dr Kooner's published outcomes have been favourable2.
Robot-assisted pyeloplasty - the preferred option
Dr Kooner performs robotic-assisted pyeloplasty at a hospital that has the robotic surgical system. Small incisions are made in the abdomen, the robotic arms are docked, and Dr Kooner operates from a console, with his hand movements translated into precise instrument movements inside the abdomen. A fourth robotic arm is used to retract the bowel to create working space.
The narrow segment is excised and the renal pelvis is stitched to the ureter. The robot offers 10× magnification and a three-dimensional view - effectively operating under an operating microscope - which allows a very accurate join.
Laparoscopic (non-robotic) pyeloplasty is possible but harder, because the instruments only open and close and cannot rotate, making the join less precise4.
Outcomes and recovery
After robot-assisted pyeloplasty, most patients are out of hospital in about two days and back to normal activity within about a week - rather than the two- to three-month recovery required after open surgery. Published literature reports success rates above 95% for robotic pyeloplasty5, and Dr Kooner's series has shown complete relief of obstruction in all patients treated2. Robotic pyeloplasty has a higher success rate than endopyelotomy6 and is now the treatment of choice.
Dr Kooner considers robot-assisted pyeloplasty the gold standard for PUJ obstruction, and believes every patient with PUJ obstruction should at least be informed about the robotic option.
References
- Laparoscopic Pyeloplasty - https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/laparoscopic-pyeloplasty
- A. Al-Sameraaii, Avi Raman, Chisum Yuen, R. Kooner - Robotically-assisted laparoscopic pyeloplasty (RALP). Utilisation of the robotic 4(th) arm in dismembered pyeloplasty - a review of the first 9 cases in NSW - https://www.researchgate.net/publication/295702706_Robotically-assisted_laparoscopic_pyeloplasty_RALP_Utilisation_of_the_robotic_4th_arm_in_dismembered_pyeloplasty_-_a_review_of_the_first_9_cases_in_NSW
- Muhammad Elmussareh, Olivier Traxer, Bhaskar Kumar Somani - Laser Endopyelotomy in the Management of Pelviureteric Junction Obstruction in Adults: A Systematic Review of the Literature - https://doi.org/10.1016/j.urology.2017.04.018
- Rajeev Kumar and Brusabhanu Nayak - Robotic versus conventional laparoscopic pyeloplasty: A single surgeon concurrent cohort review - Indian J Urol. 2013 Jan-Mar; 29(1): 19–21. doi: 10.4103/0970-1591.109978
- Stefano Moretto, Carlo Gandi, Riccardo Bientinesi - Robotic versus Open Pyeloplasty: Perioperative and Functional Outcomes - J Clin Med. 2023 Apr; 12(7): 2538. Published online 2023 Mar 28. doi: 10.3390/jcm12072538
- Bruce L. Jacobs, Julie C. Lai, Rachana Seelam - The Comparative Effectiveness of Treatments for Ureteropelvic Junction Obstruction - Urology Volume 111, January 2018, Pages 72-77