Robotic Pyeloplasty, Transperitoneal approach
Patient positioning is similar to other interventions of the upper urinary tract, and trocar placement is as follows:
A 12-mm camera trocar is inserted through the umbilicus in slim patients and more laterally in obese patients (pararectal line). Two 8-mm robotic trocars are placed along the anterior axillaryline. The third 8-mm robotic trocar is placed on themidclavicular line below the costal margin. A conventional laparoscopic trocar could be placed on the lateral margin of the rectus muscle near the pubic bone. A 30optic is used. Insufflation pressure is set at 12 mmHg
After dissection of Toldt’s line, the ureter is identified and elevated using the fourth robotic arm
Dissection proceeds along the ureter, in order to find the renal pelvis, and any crossing vessels obstructing the UPJ (in this case, the ureter is to be transposed anterior to the new anastomosis)
Once the UPJ is properly identified and freed of adhesions, the stenosed segment may be excised.
Any redundant tissue in a widely dilated pelvis may be excised at this step
The ureter should be spatulated in its lateral aspect for approx. 2 cm.
Then, the stent is inserted through a large bore IV needle over a guide wire, and inserted through the ureter.
The suture of the anastomosis may be done with a continuous or a interrupted 3/0 Vicryl suture, provided there is no tension of the suture line. The first suture joins the lower end of the spatulated ureter to the lower end of the incision in the renal pelvis.
When the anastomosis is finished, a drain should be inserted.