Minimally invasive surgical management of pelvic‐ureteric junction obstruction: update on the current status of robotic‐assisted pyeloplasty

Abstract

BACKGROUND Pelvi‐ureteric junction (PUJ) obstruction is characterized by a functionally significant impairment of urinary transport caused by intrinsic or extrinsic obstruction in the area where the ureter joins the renal pelvis. The majority of cases are congenital in origin; however, acquired conditions at the level of the ureteropelvic junction may also present with symptoms and signs of obstruction. Historically, open pyeloplasty and endoscopic techniques have been the main surgical options with the intent of complete excision or incision of the obstruction. The advent of laparoscopy and robotic‐assisted applications has allowed for minimally invasive reconstructive surgery that mirrors open surgical techniques. AIMS We review the current status of robotic‐assisted laparoscopic pyeloplasty and report on the result, continuing evolution, and potential role for this surgical procedure. MATERIALS AND METHODS A review of the recent literature encompassing laparoscopic and robotic‐assisted pyeloplasty was conducted with particular attention to operative techniques, surgical outcomes, and complication rates. RESULTS Laparoscopic and robotic‐assisted approaches are able to duplicate the open technique, and not surprisingly, are now being shown to be as efficacious as the gold standard open approach. The laparoscopic remains technically challenging due to the high proficiency level required for intracorporeal suturing, although added experience has resulted in shorter operative times. The advent of robotics has further expanded the breadth of this reconstructive procedure while preserving the benefits of decreased pain, shorter hospitalization, rapid convalescence, and an improved cosmetic result. DISCUSSION The introduction of robotics to the field of minimally invasive surgery facilitates this procedure and may allow for more widespread implementation by surgeons of varying skill levels. These benefits must be balanced against the increased costs of the robotic platform. CONCLUSION Clinical reports have demonstrated that robotic‐assisted pyeloplasty is a safe, feasible, and effective technique for treating ureteropelvic junction obstruction in short term studies. Additional studies with prolonged follow‐up will ultimately provide valuable information as to the long‐term efficacy of robotic‐assisted laparoscopic pyeloplasty.

Hydronephrosis in the course of ureteropelvic junction obstruction - an underestimated problem?Current opinion on pathogenesis, diagnosis and treatment.

“…Clinical trials have shown that robotic pyeloplasty is a safe, feasible and effective procedure for treating UPJO. 35 A review and meta-analysis of the literature demonstrated that robotic pyeloplasty was associated with a 10-min reduction in operative time and significantly shorter hospital stays compared with the LP approach. However, there were no differences between the techniques concerning the rates of success and complications.…”

Transperitoneal Robot-Assisted Laparoscopic Pyeloplasty

“…8,9 Recent reports suggest that robotassisted pyeloplasty has equivalent success rates. 3,5 Minimally invasive surgery also offers the additional advantage of decreased postoperative pain and shorter convalescence in many of the adult series. 3,5,6 As an alternative to minimally invasive pyeloplasty, endopyelotomy has a lower success rate of 60% to 80%.…”

“…3,5 Minimally invasive surgery also offers the additional advantage of decreased postoperative pain and shorter convalescence in many of the adult series. 3,5,6 As an alternative to minimally invasive pyeloplasty, endopyelotomy has a lower success rate of 60% to 80%. 7,10 It has thus fallen out of favor as first-line therapy for primary UPJ obstruction, but it is still often used in secondary UPJ obstruction or for patients who are poor operative candidates.…”

“…Recent evidence shows that robotassisted and laparoscopic pyeloplasty have approached the success of open pyeloplasty, [1][2][3] while offering the potential for shorter recovery time and reduced postoperative pain. [4][5][6] In addition, long-term follow-up of patients who were undergoing other forms of minimally invasive treatment for ureteropelvic junction obstruction (UPJ)-in particular, endopyelotomy-has shown an increased risk of failure or recurrence relative to a pyeloplasty. 7 Despite its success, factors in patient selection and operative technique can influence the outcome of robot-assisted pyeloplasty.…”

Robotic reconstructive urology: possibilities for the urological surgeon beyond the prostate

“…The procedure lasts 1.5 hours in experienced hands and has a success rate of >95 per cent. 4 Anastomotic leaks are rare and many patients can go home on the day after RAP. Kidneys with anatomical abnormalities can be treated 5 and functional or symptomatic recurrence seems rare at three years follow-up.…”