Robot-assisted laparoscopic pyeloplasty – Benefits and risks

A pyeloplasty is a surgical procedure to repair or remove any obstruction, i.e., a blockage or narrowing (stricture), at the ureteropelvic junction where the kidney meets the ureter.

This condition in the ureter walls obstructs the urine outflow, preventing the kidney from functioning correctly, affecting its ability to drain. It brings severe pain to the patient, and over time, can damage the kidney.

Pyeloplasty unblocks the ureter and lets urine flow again. The gold standard in ureteropelvic junction obstruction (UPJO) management, pyeloplasty is done in three ways: open surgery, laparoscopic (minimally invasive) robot-assisted. Laparoscopic and robotic pyeloplasty are very popular due to lesser operative and postoperative complications.

Laparoscopic surgery, often called keyhole surgery, is carried out using several small incisions or keyholes, rather than the one large incision in the side over the ribs for traditional open surgery.

During laparoscopy, the preparation of urinary tract surfaces for the subsequent creation of anastomosis and intracorporeal suturing is generally the most technically challenging step. Cases with narrow ureters are the most difficult to manage. Inadequate laparoscopic instruments, especially for less experienced young surgeons, can be responsible for prolonged surgery and higher complication rates.

A robot-assisted laparoscopic pyeloplasty, on the other hand, offers much more accuracy, high precision, enhanced visualization, and good dexterity to the surgeons. It uses a robotic console that controls the robotic arms to perform the operation. The surgeon, sitting in the console a few feet away, carries out the procedure by controlling the robotic arms and the surgical instruments.

The da Vinci SP platform, for instance, includes three, multi-jointed, wristed arms. One robotic arm holds a high-magnification three dimensional (3D) camera inserted into your abdomen (tummy) through one of the keyholes, allowing the surgeon to see inside the abdomen, while the other robotic arms hold various instruments, which the surgeons use to carry out the operation.

A robot-assisted laparoscopic pyeloplasty brings several benefits, transforming the way surgeons operate, and patients recover.

Benefits

  • It causes less blood loss, eliminating the risk of needing a blood transfusion. Blood loss is typically about 200-300mls, whereas, in a traditional pyeloplasty, it can be more than 1,000mls.
  • Since the incisions are small, the patient feels less pain and discomfort.
  • The patients rarely need strong painkillers.
  • There is less of a need to admit the patient in the hospital for very long. Most patients go home 1-2 nights.
  • It avoids the massive scar and offers more precise suturing (stitching).
  • The likelihood of infection and other complications are less.
  • It offers a quicker full recovery. Patients can return to normal activities more quickly.

Risks

As with any surgery, a robot-assisted laparoscopic pyeloplasty presents some risks. They are:

  • Damage to structures inside the abdomen, bowel, liver, spleen, or blood vessels and other organs from the instruments.
  • Risk of hernia due to the small incisions, known as ‘port site hernia.’
  • Bleeding may lead to blood transfusion in fewer than two out of every 100 procedures.
  • A urinary leak around the kidney, joining to the ureter tube, that happens in 3-5 in 100 patients. This may require a prolonged hospital stay.
  • Complications associated with a general anaesthetic, such as irregular heartbeat, chest infection, or blood clots in the legs or lungs.
  • Wound infection, bruising around wounds, poor wound healing or weakness at the wound sites.
  • Recurrence of the narrowing due to failures of the repair in 5-10 of 100 patients.
  • Nerve compression or injury due to the pressure from the positioning of the body during the operation.
  • Need to convert to traditional open surgery.
  • There is a small risk of dying (1-2 in 100 patients).

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