Dr. Rafael F. Coelho

1. Robotic-Assisted Pyeloplasty:
Technique and Outcomes
Rafael F. Coelho
Global Robotics Institute – Florida Hospital Celebration Health
Faculdade de Medicina USP

2. Introduction
•UPJ obstruction is the most common
congenital abnormality of the ureter ( 5/100000
births)
•Historically, open dismembered pyeloplasty
has been the “gold-standard” treatment, with
documented success rates greater than 90%
•Laparoscopic Pyeloplasty- First described
1993 by Schuessler and colleagues
• Similar success rates have been reported
with LP with the advantages inherent to a
minimally invasive procedure.
Schuessler et al, J Urol, 1993
Lowe et al, Urology, 1984

3. Laparoscopic Pyeloplasty
• Emerging gold standard
• The problem !!
Not a part of mainstream urology
Provided by <1% of urologic surgeons
 Inexperience with laparoscopy
 Difficulty with intracorporeal
suturing
• A need for a more feasible approach

5. Surgical Technique

6. Stent Placement
• Retrograde prior to
positioning for pyeloplasty
UPJO
• Antegrade during
reconstruction of the UPJ

7. Patient Positioning - Transperitoneal

8. Trocar Placement - Transperitoneal
Trocar placement for Right Trocar placement for Left
Pyeloplasty Pyeloplasty

9. Trocar Placement - Tulane University

10. Trocar Placement – Vita Salute University
Cestari et al, Eur Urol, 2010

11. OR setup – Transperitoneal RAP
Cestari et al, Eur Urol, 2010

12. Trocar Placement – Retroperitoneal RAP
Cestari et al, Eur Urol, 2010

13. OR setup – Retroperitoneal Pyeloplasty
Cestari et al, Eur Urol, 2010

14. Surgical Technique
• Reflect the colon and dissect out the ureter

15. Surgical Technique
• Preserve crossing vessels (if present) and mobilize the renal pelvis

16. Surgical Technique
• Locate and excise the UPJO

17. Surgical Technique
• Spatulate ureter laterally, Transpose anteriorly?

18. • Anterior Transposition?
When the ureter appeared to be
on stretch with
transposition, the crossing
vessel was not transposed

19. • Anterior Transposition?
• Based on renal scan, imaging and symptomatic improvement a
comparison of RALP outcomes revealed similar success rates in
patients with crossing vessels with or without transposition of the
ureteropelvic junction anastomosis.
•
• Transposition of the anterior crossing vessel should be an
intraoperative decision and only performed when dictated by the
anatomical relation.
Boylu et al, J Urol, 2010

20. Surgical Technique
• Anastomosis (4-0 monocryl suture on RB-1 needle)

21. Surgical Technique
• JP drain

22. Outcomes

23. Critical Analysis of Robotic-Assisted Laparoscopic
Dismembered Pyeloplasty For Primary and Secondary
Ureteropelvic Junction Obstruction: A Multi-Institutional
Experience
Vipul R. Patel, Ananthakrishnan Sivaraman, Rafael F Coelho, Manoj Patel, Sanket
Chauhan, Kenneth Palmer, Ravi Munver, Jorge E. Bracho II,Vincent G. Bird,
Raymond J. Leveillee

24. •Retrospective review of prospectively collected data from three
academic institutions
• 168 patients who underwent RALDP for UPJO between June
2002 and October 2008, were analyzed
•161 patients undewent Anderson-Hynes RALDP and 7 pts Foley
Y-V plasty.
•All cases were performed via transperitoneal approach
•Anastomosis -Two five inch 4-0 running monocryl sutures on
RB-1

25. Etiology: Secondary Pyeloplasty Repairs
Procedure No.
Previous Open Pyeloplasty 7
Previous Laparoscopic Pyeloplasty 1
Previous Laser Endopyelotomy 9
Previous Electrosurgical cutting balloon
Endopyelotomy
3
Previous Open Pyeloplasty and Laser
Endopyelotomy
1
Total 21

26. Results
Overall Primary Repair Secondary Repair
Number of Patients (N) 168 147 (87.5%) 21 (12.5%)
Mean Age (years) 37.6 (19-71) 37.8 36.0
Sex (F/M) 94/74 82/65 12/9
BMI 25.57 (17.2-43.5) 25.5 26.7
Side (R/L) 96/72 88/59 8/13
Intrinsic Etiology 93/168 (55.4%) 84/147 (57%) 9/21 (43%)
Crossing Vessel Etiology 75/168 (44.6%) 63/147 (43%) 12/21 (57%)
Mean OR Time (Minutes) 134.87 125.95 190.4
Mean Estimated Blood Loss (EBL) 48.67 42.92 86.2
Mean Length of Stay (days) (LOS) 1.48 (1-7) 1.45 1.7

27. Results
Overall Primary Repair Secondary Repair
Symptom Resolution 157/164 (95.7%) 138/143 (96.5%) 19/21 (90.5%)
T half-life Improvement 96.9% 96.5% 100%
Renal Function Improvement 72.7% 73.3% 67%
Pre-Op GFR (mL/min/1.73 m2) 82.79 (41.4-127) 80.86 99.25
Post-Op GFR (mL/min/1.73 m2) 90 (53-151) 86.45 112.25
GFR Improvement 51.7% 48% 67%

28. Results - Complications
Overall Primary Secondary
Complications 11/168 (6.6%) 8/147 (5.4%) 3/21 (14.2%)
Blood Transfusion 3 2 1
Ileus 4 3 1
Post-Op
UTI/Pyelonephritis
1 1 0
Urine Leak 3 2 1
Need for second
procedure
6 4 2
• Retrograde Laser • Retrograde Laser
Endopyelotomy (2 cases) Endopyelotomy (1 case)
• Retrograde Balloon • Re-Stenting - Clot retention
Endopyelotomy (1 case) in renal pelvis (1 case)
• Re-Stenting - Clot retention in
renal pelvis (1 case)

29. Robotic-Assisted Pyeloplasty: Current Outcomes
Singh et al, Can J Urol, 2010

30. Robotic-Assisted Pyeloplasty: Current Outcomes
Reference
No. Approach Operative Technique Ports Stenting Hospital Follow up Success Complic
of Time Stay (mo) Rate ation
Cases (min) (days) (%) rate
Mendez- 32 Trans 300 Dismembered 4 total / 3 RG 100% 1.1 8.6 mo 3%
Torres et al. (31), Fenger robotic (1.5-16) 94%
(1)
Siddiq et al. 26 Trans 245 Dismembered 4 (46%) and 0%
(165-390) (23) 3 (54%) RG 100% 2 6 mo 95% major/
Y-V (3) total / 3 (2-12) 11.5%
robotic minor
122 4 total / 3 11.7
Patel 50 Trans (60-330) Dismembered robotic RG 100% 1.1 (1–28) 0%
96%
108.3 4 total / 3 39.1 mo
Schwenter et 92 Trans (72-215) Dismembered robotic AG 94% 4.6 (3-73) 96.7% 3%
al RG 6%
4 or 5 total 29 7.1%
Muffarij at al. 140 Trans 217 Dismembered / 3 robotic AG 71% 2.1 (3-63) 95.7% major /
except 1 (80-510) RG 29% 2.9%
case retro minor

31. Robotic vs. Pure Lap Pyeloplasty

32. Robotic vs. Pure Lap Pyeloplasty

33. Operative Time

34. Operative Time

35. LOS

36. LOS

37. Complication Rates

38. Complication Rates

39. Success Rates

40. Success Rates

41. Conclusion
“RAP and CLP appear to be equivalent with
regard to postoperative urinary leaks,
hospital readmissions, and success rates….”

42. Robotic Pyeloplasty with Concomitant
Stone Removal
Technique
• After the UPJ has been incised, reduction pyeloplasty
performed, as indicated.
• The cephalad arm of the robot is undocked
• This trocar and the bedside surgeon’s trocar site used
for stone removal
• One trocar for flexible nephroscope and the other
trocar for suction irrigator
Atug, Thomas et al, BJU, 96:1365-1368, 2005

43. Suction
Robotic
Flexible
Pyeloplasty Nephroscope
with
Concomitant
Stone Removal

44. Concomittant
Stone Removal

46. RALDP vs. Pure Lap - Costs
•Mathematical cost model:
RLP 2.7 times more
expensive than LP
•If Robot depreciation is
excluded: RALDP 1.7 times
more expensive
•LP time must increase to 6.5
hs to become cost
equivalent to RALDP
Link RE et al. Ann Surg, 2006

47. Costs
•More than 500 RALDP cases,
with operative times less than 130
minutes per case, would need to
be performed per year to achieve
costs equivalent to laparoscopic
pyeloplasty
Bhayani S et al. J Endourol, 2005

48. Costs
LP is more cost effective than
CP if LP is performed in 338
minutes
Bhayani S et al. J Endourol, 2005

49. Conclusions
•RALDP is a safe, efficacious and viable option for primary or
secondary repair of UPJO with excellent success rates and low
incidence of complications
•May benefit patients by enabling a greater number of urologists
with limited laparoscopic reconstructive expertise to offer a
minimally invasive approach to correction of UPJO
• Less cost-effective than Laparoscopic Pyeloplasty