Robotic-Assisted Pyeloplasty:       Technique and Outcomes                     Rafael F. CoelhoGlobal Robotics Institute –...
Introduction•UPJ obstruction is the most commoncongenital abnormality of the ureter ( 5/100000births)•Historically, open d...
Laparoscopic Pyeloplasty• Emerging gold standard• The problem !!  Not a part of mainstream urology  Provided by <1% of uro...
Surgical Technique
Stent Placement• Retrograde         prior   to    positioning for pyeloplasty                                        UPJO•...
Patient Positioning - Transperitoneal
Trocar Placement - TransperitonealTrocar placement for Right   Trocar placement for Left       Pyeloplasty                ...
Trocar Placement - Tulane University
Trocar Placement – Vita Salute University                      Cestari et al, Eur Urol, 2010
OR setup – Transperitoneal RAP                  Cestari et al, Eur Urol, 2010
Trocar Placement – Retroperitoneal RAP                      Cestari et al, Eur Urol, 2010
OR setup – Retroperitoneal Pyeloplasty                         Cestari et al, Eur Urol, 2010
Surgical Technique•   Reflect the colon and dissect out the ureter
Surgical Technique•   Preserve crossing vessels (if present) and mobilize the renal pelvis
Surgical Technique• Locate and excise the UPJO
Surgical Technique• Spatulate ureter laterally, Transpose anteriorly?
• Anterior Transposition?When the ureter appeared to beon          stretch        withtransposition,    the  crossingvesse...
• Anterior Transposition?• Based on renal scan, imaging and symptomatic improvement a  comparison of RALP outcomes reveale...
Surgical Technique• Anastomosis (4-0 monocryl suture on RB-1 needle)
Surgical Technique•   JP drain
Outcomes
Critical Analysis of Robotic-Assisted Laparoscopic Dismembered Pyeloplasty For Primary and SecondaryUreteropelvic Junction...
•Retrospective review of prospectively collected data from threeacademic institutions• 168 patients who underwent RALDP fo...
Etiology: Secondary Pyeloplasty RepairsProcedure                                  No.Previous Open Pyeloplasty            ...
Results                                   Overall              Primary Repair   Secondary RepairNumber of Patients (N)    ...
Results                               Overall             Primary Repair     Secondary RepairSymptom Resolution           ...
Results - Complications                        Overall                 Primary                           SecondaryComplica...
Robotic-Assisted Pyeloplasty: Current Outcomes                            Singh et al, Can J Urol, 2010
Robotic-Assisted Pyeloplasty: Current Outcomes Reference                   No.    Approach     Operative    Technique     ...
Robotic vs. Pure Lap Pyeloplasty
Robotic vs. Pure Lap Pyeloplasty
Operative Time
Operative Time
LOS
LOS
Complication Rates
Complication Rates
Success Rates
Success Rates
Conclusion“RAP and CLP appear to be equivalent withregard to postoperative urinary leaks,hospital readmissions, and succes...
Robotic Pyeloplasty with Concomitant                  Stone RemovalTechnique• After the UPJ has been incised, reduction py...
Suction   Robotic                            Flexible Pyeloplasty              Nephroscope     with ConcomitantStone Removal
ConcomittantStone Removal
RALDP vs. Pure Lap - Costs•Mathematical cost model:RLP    2.7    times moreexpensive than LP•If Robot depreciation isexclu...
Costs•More than 500 RALDP cases,with operative times less than 130minutes per case, would need tobe performed per year to ...
CostsLP is more cost effective thanCP if LP is performed in 338minutes                                    Bhayani S et al....
Conclusions•RALDP is a safe, efficacious and viable option for primary orsecondary repair of UPJO with excellent success r...
Robotic-Assisted Pyeloplasty
Robotic-Assisted Pyeloplasty
Upcoming SlideShare
Loading in...5
×

Robotic-Assisted Pyeloplasty

1,417

Published on

Dr. Rafael F. Coelho

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,417
On Slideshare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
0
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Robotic-Assisted Pyeloplasty

  1. 1. Robotic-Assisted Pyeloplasty: Technique and Outcomes Rafael F. CoelhoGlobal Robotics Institute – Florida Hospital Celebration Health Faculdade de Medicina USP
  2. 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. 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. 4. Surgical Technique
  5. 5. Stent Placement• Retrograde prior to positioning for pyeloplasty UPJO• Antegrade during reconstruction of the UPJ
  6. 6. Patient Positioning - Transperitoneal
  7. 7. Trocar Placement - TransperitonealTrocar placement for Right Trocar placement for Left Pyeloplasty Pyeloplasty
  8. 8. Trocar Placement - Tulane University
  9. 9. Trocar Placement – Vita Salute University Cestari et al, Eur Urol, 2010
  10. 10. OR setup – Transperitoneal RAP Cestari et al, Eur Urol, 2010
  11. 11. Trocar Placement – Retroperitoneal RAP Cestari et al, Eur Urol, 2010
  12. 12. OR setup – Retroperitoneal Pyeloplasty Cestari et al, Eur Urol, 2010
  13. 13. Surgical Technique• Reflect the colon and dissect out the ureter
  14. 14. Surgical Technique• Preserve crossing vessels (if present) and mobilize the renal pelvis
  15. 15. Surgical Technique• Locate and excise the UPJO
  16. 16. Surgical Technique• Spatulate ureter laterally, Transpose anteriorly?
  17. 17. • Anterior Transposition?When the ureter appeared to beon stretch withtransposition, the crossingvessel was not transposed
  18. 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. 19. Surgical Technique• Anastomosis (4-0 monocryl suture on RB-1 needle)
  20. 20. Surgical Technique• JP drain
  21. 21. Outcomes
  22. 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. 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. 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. 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. 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. 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. 28. Robotic-Assisted Pyeloplasty: Current Outcomes Singh et al, Can J Urol, 2010
  29. 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. 30. Robotic vs. Pure Lap Pyeloplasty
  31. 31. Robotic vs. Pure Lap Pyeloplasty
  32. 32. Operative Time
  33. 33. Operative Time
  34. 34. LOS
  35. 35. LOS
  36. 36. Complication Rates
  37. 37. Complication Rates
  38. 38. Success Rates
  39. 39. Success Rates
  40. 40. Conclusion“RAP and CLP appear to be equivalent withregard to postoperative urinary leaks,hospital readmissions, and success rates….”
  41. 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. 42. Suction Robotic Flexible Pyeloplasty Nephroscope with ConcomitantStone Removal
  43. 43. ConcomittantStone Removal
  44. 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. 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. 46. CostsLP is more cost effective thanCP if LP is performed in 338minutes Bhayani S et al. J Endourol, 2005
  47. 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

×