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Robotic-assisted pyeloplasty for ureteropelvic junction obstruction

Introduction

We present a case of ureteropelvic junction obstruction secondary to aberrant crossing gonadal vessels in a symptomatic 11-year-old female with horseshoe kidney, treated with a robotic-assisted pyeloplasty.

Diagnostic Evaluation

The patient presented with intermittent right-sided flank pain and vomiting. Renal ultrasound showed right-sided hydronephrosis and an abnormal-shaped kidney. MAG-3 renal scan demonstrated decreased function of the right kidney and no drainage. A MR Urogram showed a horseshoe type kidney with malrotation and an anterior dilated renal pelvis.

Surgical Technique

The patient underwent a robotic-assisted dismembered pyeloplasty. Intraoperatively, the right kidney was confirmed to be malrotated with a large, anteriorly directed renal pelvis. A packet of aberrant crossing gonadal vessels was identified and dissected from the right ureter and surrounding tissue. The ureter was sharply divided at the level of the ureteropelvic junction and transposed above the crossing vessels. A tension free mucosal to mucosal water-tight anastomosis was performed starting at the apex of the incision. A double-J stent was introduced into the ureter. The remainder of the anastomosis was completed with interrupted sutures. There were no intraoperative or postoperative complications.

Conclusions

Robotic-assisted dismembered pyeloplasty is a safe and effective method for UPJO correction in symptomatic patients with complex renal anatomy.

An 11-year-old female presented with intermittent right-sided flank pain and vomiting. The patient underwent a robotic-assisted dismembered pyeloplasty. Intraoperatively, the right kidney was confirmed to be malrotated with a large, anteriorly directed renal pelvis. A packet of aberrant crossing gonadal vessels was identified and dissected from the right ureter and surrounding tissue. The ureter was sharply divided at the level of the ureteropelvic junction and transposed above the crossing vessels. Using a 4-0 Vicryl suture on a RB-1 needle, a tension free mucosal to mucosal water-tight anastomosis was performed starting at the apex of the incision. A 0.038in sensor wire was advanced into the bladder and a 4.8Fr x 20cm double-J stent was introduced over the wire. The sensor wire was removed and the proximal coil of the double-J stent was placed into the renal pelvis. The remainder of the anastomosis was completed with interrupted sutures. There were no intraoperative or postoperative complications.
The indication for this procedure was symptomatic ureteropelvic junction obstruction and decreased renal function.
Contraindications include an active urinary tract infection.
Subxiphoid 8mm port (3rd Arm) Umbilical 8mm Camera port (2nd Arm) Right Lower Quadrant Abdominal 8mm port (1st Arm) Left Upper Quadrant Abdominal 5mm AirSeal port (Assistant Port)
In our case, the patient presented with intermittent right-sided flank pain and vomiting. Pre-operative renal ultrasound was significant for right-sided hydronephrosis and an abnormal-shaped kidney. MAG-3 renal scan showed decreased function of the right kidney and no drainage. Due to her abnormal anatomy, an MR urogram was obtained and showed a horseshoe type kidney with malrotation and an anterior dilated renal pelvis.
Intraoperatively, the right kidney was confirmed to be malrotated with a large, anteriorly directed renal pelvis. A packet of aberrant crossing gonadal vessels was identified and dissected free from the right ureter and surrounding tissue.
In cases of ureteropelvic junction obstruction in asymptomatic patients with preserved renal function, observation and serial ultrasounds is an option. However, indications for surgical intervention include decreased or worsening renal function, recurrent pain, or recurrent UTIs. Robotic-assisted pyeloplasty has become a popular method of correcting UPJ obstructions and is now the most frequently performed robotic surgery in pediatrics. It confers the minimally invasive advantages of laparoscopic pyeloplasty with reduced technical difficulties. Robotic-assisted dismembered pyeloplasty is a safe and effective method for UPJO correction in symptomatic patients with complex renal anatomy and variants.
Recurrent UPJ obstruction can occur postoperatively if the obstructive area is incompletely resected or if crossing vessels are inadequately identified. Other complications include ureteral damage, as well as risks of damage to surrounding neurovasculature, which can be mitigated with adequate mobilization and visualization. Placement of ureteral stents helps reduce the risk of urinary leakage and urinoma formation post-operatively. Risks specific to robotic-assisted pyeloplasty include bowel or vessel injury during trochar placement.
There are no conflicts to be disclosed.
Thank you to all who assisted in the surgery and production of this video.
[1] Baskin, L. S., Kogan, B. A., & Stock, J. A. (2005). Handbook of pediatric urology. Philadelphia, PA: Wolters Kluwer. [2] Das S, Amar AD, Ureteropelvic Junction Obstruction with Associated Renal Anomalies, The Journal of Urology. 1984;131(5):872-874. [3] Taghavi K, Kirkpatrick J, Mirjalili SA, The horseshoe kidney: Surgical anatomy and embryology, Journal of Pediatric Urology. 2016;12(5):275-280. [4] Passoni NM, Peters CA, Managing Ureteropelvic Junction Obstruction in the Young Infant, Frontiers in Pediatrics. 2020;8:242. [5] Morales-López RA., Pérez-Marchán M, Pérez BM, Current Concepts in Pediatric Robotic Assisted Pyeloplasty, Frontiers in Pediatrics. 2019;7:4.

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