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.

Difficult Dissection during a Low Anterior Resection

It is well-accepted that recurrent or complicated diverticulitis is an indication for surgical resection. Minimally invasive techniques, like the daVinci robot, have been developed to enable better visualization of the pelvis with articulating instruments. However, many times, the minimally invasive approach is deferred for cases of severe disease and adhesions. This video demonstrates the dissection of a significantly diseased sigmoid colon during a robotic-assisted low anterior resection. As you can see, with surgeon experience and patience, even complicated cases can be done successfully using the robot.

The patient is a 65-year-old male with a history of multiple episodes of diverticulitis. The most recent episode was complicated by a pericolonic abscess, which was treated non-operatively with drainage and antibiotics. He presents 2 months later for an elective resection.

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