Dr Kooner explains how robot-assisted pyeloplasty is performed, why he prefers it for UPJ obstruction, and how it compares with endopyelotomy and open surgery. Full transcript on the resources page.
Indications
Robotic pyeloplasty is appropriate for most adults with:
- Symptomatic UPJ obstruction (intermittent loin pain, recurrent infections, stones, or declining function).
- Imaging evidence of obstruction: CT urogram showing a narrow UPJ with a dilated renal pelvis, and a MAG3 renogram drainage half-time longer than about 20 minutes after frusemide.
- A crossing lower-pole vessel kinking the UPJ (the robot makes it straightforward to move the ureter in front of or behind the vessel).
- Previous failed endopyelotomy.
- Reasonable fitness for a general anaesthetic and pneumoperitoneum.
How it is done
The operation is a dismembered pyeloplasty: the narrow segment is completely cut out and the healthy ureter is re-joined to a healthy part of the renal pelvis. Step by step:
- General anaesthetic. A ureteric catheter or pre-placed stent is sometimes used to mark the ureter.
- Four small keyhole incisions are made in the abdomen (usually 8 mm ports for the robotic arms and one slightly larger assistant port).
- Carbon dioxide gas is used to create working space.
- The robot is docked. Dr Kooner moves to a console, where his hand movements are translated into precise, tremor-free movements of articulated instruments inside the abdomen with 10× magnification and a three-dimensional view.
- The fourth robotic arm retracts the bowel out of the way so the operative field stays open without needing an assistant to hold anything - a technique Dr Kooner has presented in the first NSW case series.
- The narrowed UPJ is identified. Any crossing vessel is moved out of the way.
- The narrow segment is excised and the ureter is spatulated so the new join has a wide opening.
- The ureter is sewn to the renal pelvis with fine absorbable stitches. A double-J ureteric stent is placed across the repair before the last stitches close it.
- A small drain is sometimes left for one or two days. The port sites are closed.
Why robotic rather than laparoscopic?
In standard laparoscopy the instrument tips do not rotate - they only open and close - so a precise, watertight join is much harder to sew. The robot gives 7 degrees of instrument freedom, 3D vision, and the fourth-arm retractor. The join is effectively performed under an operating microscope. Compared with open pyeloplasty, the robotic approach avoids the 15 to 20 cm flank incision that drives most of the pain and the two- to three-month recovery.
Hospital stay and recovery
- Admission on the day of surgery.
- About two days in hospital.
- Desk-based work usually possible within one to two weeks.
- Strenuous work, sport, or heavy lifting: four to six weeks.
- Internal ureteric stent stays in place for four to six weeks, removed in a short day-case procedure.
- MAG3 renogram at three to six months confirms the kidney is draining well.
Risks and considerations
- General anaesthetic risks and port-site bleeding or infection.
- Temporary stent symptoms: urinary frequency, mild flank ache, a little blood in the urine.
- Urine leak from the new join while the stent is still in place - usually self-limiting.
- Rarely, the repair narrows again over time (restenosis), which is picked up on surveillance imaging.
- Conversion to an open operation - uncommon but always discussed as a possibility.
Outcomes
Published international series report long-term success above 95% for robotic pyeloplasty. Dr Kooner's NSW series had complete relief of obstruction in all patients treated. Robotic pyeloplasty has a higher success rate than retrograde endopyelotomy and matches, or exceeds, open pyeloplasty - with a fraction of the recovery time. See the outcomes page for the full evidence summary.
Alternatives