Robotic pyeloplasty

The problem: PUJ obstruction

The kidney makes urine and drains it into a collecting area called the renal pelvis. The renal pelvis then narrows down into a thin tube (the ureter) that carries urine to the bladder.

If the join between the renal pelvis and the ureter is too narrow, urine cannot drain properly. The kidney swells. This is called PUJ obstruction (pelvi-ureteric junction obstruction, sometimes also called UPJ obstruction).

Most people are first diagnosed because of severe pain in the loin, similar to a kidney stone. In some patients, it is found by chance on a scan done for something else.

The traditional treatment: open surgery

For a long time, this condition was treated by an open operation, with a long cut along the side of the loin. It works well, but the recovery is significant: usually seven to ten days in hospital and two to three months before normal activity. This is why minimally invasive options have largely replaced open surgery.

The keyhole option: laser endopyelotomy

For some patients, the narrowing can be treated through the urethra without any external cuts at all:

• A small telescope is passed up to the renal pelvis.
• A holmium laser is used to cut through the narrow segment.
• A balloon stretches the area open.
• A stent (a thin tube) is left in for about six weeks while it heals.

Success rates are around 75%, which is lower than for surgical reconstruction. There is also a small risk of bleeding if a blood vessel sits in the path of the laser cut. This option is most useful for patients whose previous treatment has failed, or who want to avoid abdominal surgery.

The preferred option: robotic pyeloplasty

This is the operation Dr Kooner now considers the standard for most patients. The principles are the same as the old open operation, but the surgery is done through small cuts using the robotic system:

• A few small cuts are made in the abdomen.
• The robotic instruments and camera are passed in.
• A fourth robotic arm holds the bowel out of the way to make space.
• The narrow segment of the kidney drainage tube is cut out.
• The renal pelvis is then very precisely stitched to the ureter, like joining two pieces of pipe.

The 10 times magnification and three-dimensional view help with the precision of the join.

What recovery is like

• Most patients are out of hospital in about two days.
• Most are back to normal activity in about a week, instead of the two to three months after open surgery.
• A stent is usually left inside for several weeks while the join heals, and is then removed in a small day-case procedure.

Published success rates for robotic pyeloplasty are over 95% in good hands.