Pediatric Robot-Assisted Laparoscopic Pyeloplasty Using a Transmesenteric Approach

Abstract

Introduction: Robot-assisted laparoscopic pyeloplasty is an emerging minimally invasive option in the pediatric population for the treatment of ureteropelvic junction obstruction. Since the first description of minimally invasive pyeloplasty in 1993,1 the robot-assisted technique has been applied to both primary and reoperative procedures in the pediatric population, achieving results comparable to open surgery.2–4 We describe our transmesenteric approach for robot-assisted laparoscopic pyeloplasties, which provides direct access to the pelvis without mobilization of the colon. Materials and Methods: After induction of anesthesia and insertion of a Foley catheter, the patient is secured with tape in the supine position with the ipsilateral side raised on a gel roll such that the patient is at a 45° angle to the bed. Initial access is performed using an open peritoneal (Hasson) technique. One 8.5- or 12-mm camera port, two robotic arm ports (5 or 8 mm), and one 5-mm accessory port are used for the procedure. The bed is then rotated to elevate the ipsilateral side. The Da Vinci surgical robotic system (Intuitive Surgical, Sunnyvale, CA) is docked over the ipsilateral side to the ports. A small window is made in the mesentery overlying the dilated renal pelvis while taking care to avoid major vasculature and the renal pelvis is dissected free. A “hitch stitch” is placed through the abdominal wall, through the renal pelvis, and then through the abdominal wall to provide exposure and traction during subsequent dissection and reconstruction. The ureteropelvic junction is transected proximal to the obstruction and the ureter is spatulated until a healthy lumen is visible. The ureteropelvic junction is then reconstructed with running 5-0 Monocryl sutures, using the strictured portion temporarily as a handle until excision just before completion of the anastamosis. Finally, the mesenteric window is closed with a running 4-0 Vicryl suture. Results and Conclusions: Robot-assisted laparoscopic pyeloplasty using a transmesenteric approach provides rapid identification of as well as easy access to the ureteropelvic junction obstruction in children. Observation of the dilated renal pelvis through the mesentery allows for exposure through avascular planes, obviating colon mobilization. Complete reconstruction can be performed without extensive colonic mobilization, preserving the retro-colic space. Transmesenteric robot-assisted laparoscopic pyeloplasty is an attractive alternative to previously described robotic pyeloplasty techniques for the treatment of ureteropelvic junction obstruction in children. No competing financial interests exist. Runtime of video: 7 mins 11 secs.