Robot-Assisted Transumbilical Laparoendoscopic Single-Site Pyeloplasty: Technique and Perioperative Outcomes from a Single Institution

Abstract

Transumbilical laparoendoscopic single-site (U-LESS) pyeloplasty may provide improved cosmesis compared with conventional laparoscopic pyeloplasty. However, U-LESS pyeloplasty can be challenging because of the need for extensive suturing. The wristed instrumentation of robot-assisted laparoendoscopic single-site (R-LESS) pyeloplasty provides improved dexterity to facilitate intracorporeal suturing. We therefore present our technique and experience with R-LESS pyeloplasty for ureteropelvic junction obstruction (UPJO). The da Vinci(®) S or Si Surgical System (Intuitive Surgical, Sunnyvale, CA) was used in all cases. Ureteral stents were placed cystoscopically at the start of each case. A 3-cm skin incision was made adjacent to the umbilicus. Three ports (12 mm, 8 mm, and 5 mm) were placed either through separate fascial incisions or into a GelPort(®) (Applied Medical, Rancho Santa Margarita, CA). Key techniques included port staggering, a "chopstick" arrangement of the instruments, and use of a 30° lens in an upward configuration. Traditional dismembered pyeloplasty procedures were performed in all cases. Patients less than 45 years of age with no prior abdominal surgery were offered this approach. Eight patients (4 female; 5 right-sided; median age, 22 years) underwent R-LESS pyeloplasty without the need for additional ports. All patients were discharged by the third postoperative day, and 5 were discharged on Day 1. One patient experienced urine leakage, which was managed with a temporary nephrostomy tube. Length of follow-up ranged from 29 to 46 months. No patients have developed symptoms or radiographic evidence of recurrent UPJO. R-LESS pyeloplasty can be safely performed for selected patients with currently available robotic equipment. Careful patient selection and case setup are key to successfully performing these procedures.