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Robotic-Assisted Pyeloplasty

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Dr. Rafael F. Coelho

Dr. Rafael F. Coelho

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  • 1. Robotic-Assisted Pyeloplasty: Technique and Outcomes Rafael F. CoelhoGlobal Robotics Institute – Florida Hospital Celebration Health Faculdade de Medicina USP
  • 2. Introduction•UPJ obstruction is the most commoncongenital abnormality of the ureter ( 5/100000births)•Historically, open dismembered pyeloplastyhas been the “gold-standard” treatment, withdocumented success rates greater than 90%•Laparoscopic Pyeloplasty- First described1993 by Schuessler and colleagues• Similar success rates have been reportedwith LP with the advantages inherent to aminimally 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
  • 4. Surgical Technique
  • 5. Stent Placement• Retrograde prior to positioning for pyeloplasty UPJO• Antegrade during reconstruction of the UPJ
  • 6. Patient Positioning - Transperitoneal
  • 7. Trocar Placement - TransperitonealTrocar placement for Right Trocar placement for Left Pyeloplasty Pyeloplasty
  • 8. Trocar Placement - Tulane University
  • 9. Trocar Placement – Vita Salute University Cestari et al, Eur Urol, 2010
  • 10. OR setup – Transperitoneal RAP Cestari et al, Eur Urol, 2010
  • 11. Trocar Placement – Retroperitoneal RAP Cestari et al, Eur Urol, 2010
  • 12. OR setup – Retroperitoneal Pyeloplasty Cestari et al, Eur Urol, 2010
  • 13. Surgical Technique• Reflect the colon and dissect out the ureter
  • 14. Surgical Technique• Preserve crossing vessels (if present) and mobilize the renal pelvis
  • 15. Surgical Technique• Locate and excise the UPJO
  • 16. Surgical Technique• Spatulate ureter laterally, Transpose anteriorly?
  • 17. • Anterior Transposition?When the ureter appeared to beon stretch withtransposition, the crossingvessel was not transposed
  • 18. • 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
  • 19. Surgical Technique• Anastomosis (4-0 monocryl suture on RB-1 needle)
  • 20. Surgical Technique• JP drain
  • 21. Outcomes
  • 22. Critical Analysis of Robotic-Assisted Laparoscopic Dismembered Pyeloplasty For Primary and SecondaryUreteropelvic 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
  • 23. •Retrospective review of prospectively collected data from threeacademic institutions• 168 patients who underwent RALDP for UPJO between June2002 and October 2008, were analyzed•161 patients undewent Anderson-Hynes RALDP and 7 pts FoleyY-V plasty.•All cases were performed via transperitoneal approach•Anastomosis -Two five inch 4-0 running monocryl sutures onRB-1
  • 24. Etiology: Secondary Pyeloplasty RepairsProcedure No.Previous Open Pyeloplasty 7Previous Laparoscopic Pyeloplasty 1Previous Laser Endopyelotomy 9Previous Electrosurgical cutting balloonEndopyelotomy 3Previous Open Pyeloplasty and LaserEndopyelotomy 1Total 21
  • 25. Results Overall Primary Repair Secondary RepairNumber of Patients (N) 168 147 (87.5%) 21 (12.5%)Mean Age (years) 37.6 (19-71) 37.8 36.0Sex (F/M) 94/74 82/65 12/9BMI 25.57 (17.2-43.5) 25.5 26.7Side (R/L) 96/72 88/59 8/13Intrinsic 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) 134.87 125.95 190.4Mean Estimated Blood Loss (EBL) 48.67 42.92 86.2Mean Length of Stay (days) (LOS) 1.48 (1-7) 1.45 1.7
  • 26. Results Overall Primary Repair Secondary RepairSymptom 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 99.25Post-Op GFR (mL/min/1.73 m2) 90 (53-151) 86.45 112.25GFR Improvement 51.7% 48% 67%
  • 27. Results - Complications Overall Primary SecondaryComplications 11/168 (6.6%) 8/147 (5.4%) 3/21 (14.2%)Blood Transfusion 3 2 1Ileus 4 3 1Post-OpUTI/Pyelonephritis 1 1 0Urine Leak 3 2 1Need for secondprocedure 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)
  • 28. Robotic-Assisted Pyeloplasty: Current Outcomes Singh et al, Can J Urol, 2010
  • 29. 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 moSchwenter 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
  • 30. Robotic vs. Pure Lap Pyeloplasty
  • 31. Robotic vs. Pure Lap Pyeloplasty
  • 32. Operative Time
  • 33. Operative Time
  • 34. LOS
  • 35. LOS
  • 36. Complication Rates
  • 37. Complication Rates
  • 38. Success Rates
  • 39. Success Rates
  • 40. Conclusion“RAP and CLP appear to be equivalent withregard to postoperative urinary leaks,hospital readmissions, and success rates….”
  • 41. Robotic Pyeloplasty with Concomitant Stone RemovalTechnique• 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
  • 42. Suction Robotic Flexible Pyeloplasty Nephroscope with ConcomitantStone Removal
  • 43. ConcomittantStone Removal
  • 44. RALDP vs. Pure Lap - Costs•Mathematical cost model:RLP 2.7 times moreexpensive than LP•If Robot depreciation isexcluded: RALDP 1.7 timesmore expensive•LP time must increase to 6.5hs to become costequivalent to RALDP Link RE et al. Ann Surg, 2006
  • 45. Costs•More than 500 RALDP cases,with operative times less than 130minutes per case, would need tobe performed per year to achievecosts equivalent to laparoscopicpyeloplasty Bhayani S et al. J Endourol, 2005
  • 46. CostsLP is more cost effective thanCP if LP is performed in 338minutes Bhayani S et al. J Endourol, 2005
  • 47. Conclusions•RALDP is a safe, efficacious and viable option for primary orsecondary repair of UPJO with excellent success rates and lowincidence of complications•May benefit patients by enabling a greater number of urologistswith limited laparoscopic reconstructive expertise to offer aminimally invasive approach to correction of UPJO• Less cost-effective than Laparoscopic Pyeloplasty