Robotic Pyeloplasty Has Advantages

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A comparison of two types of minimally invasive surgery to repair uretero-pelvic junction (UPJ) obstruction found that robotic-assisted surgery may be faster than pure laparoscopic approach and result in less blood loss and shorter hospital stays.

In a series of 60 cases performed by a single surgeon, UPJ obstruction was managed effectively with either robotic pyeloplasty or laparoscopic pyeloplasty, and the outcomes were durable.

Compared with pure laparoscopic pyeloplasty, pure robotic pyeloplasty helped the surgeon achieve quicker dissection, reconstruction, and intracorporeal suturing with fine sutures and with antegrade double-J stenting. The robotic procedure shortened operating time significantly and provided greater ergonomic convenience.

Ashok Hemal, MD, performed robotic pyeloplasty (mainly using the transperitoneal Anderson-Hynes technique) on 30 patients (group 1) and performed laparoscopic pyeloplasty on 30 patients (group 2) in a non-randomized fashion. All patients were followed up for 18 months postoperatively.

Three robotic and one assistant port were used in group 1, and 3 or 4 ports were used in group 2. In group 1, 26 patients had antegrade double-J stenting, one had retrograde double-J stenting, and three had stentless pyeloplasty. In group 2, 22 patients had antegrade double-J stenting and eight had retrograde double-J stenting.

On average, robotic pyeloplasty was faster (98 vs. 145 minutes) and resulted in less blood loss (40 vs. 101 mL), according to findings published in the Canadian Journal of Urology (2010;17:5012-5016). The robotic procedure also resulted in a shorter hospital stay (2 vs. 3.5 days).

“This was one of the first studies where a single surgeon at one center performed both types of surgery and compared results,” said Dr. Hemal, Professor of Surgery at Wake Forest University Baptist Medical Center in Winston-Salem, N.C.

 “It allows for a more accurate comparison of surgical options than multiple physicians performing the surgeries. The results showed that robot-assisted surgery had substantial  advantages for repair of this condition. It is also generally easier for surgeons to learn in comparison to pure laparoscopy.”

In this study, all the patients received a clinical examination, an ultrasound, and a diuretic renal dynamic scan. At 18 months following their surgery, imaging studies found no obstructions in the patients in group 1 and only one obstruction in one patient in group 2. One patient in group 2 required a repeat open pyeloplasty following failed endoscopic management. Although robotic pyeloplasty had advantages, the long-term postoperative successes were equivalent on follow-up in both patient groups, Dr. Hemal said.

“The widespread use of laparoscopic surgery in reconstructive urology has been limited because it is technically challenging and requires the surgeon to be proficient in advanced suturing,” Dr. Hemal said.  “Robot-assisted surgery offers a way of overcoming some of the major impediments of laparoscopic surgery. This study shows that both the options are equally effective in hands of experienced surgeon, but robot-assistance has several advantages.”

Dr. Hemal said he expects robotic pyeloplasty to become widely available in the future and hopefully some of its higher costs can be offset by the decreased operating times and shorter hospital stays.

“Several institutions, who have robot, have adopted this procedure,” he told Renal & Urology News. “It is likely to become the new gold standard. However, the biggest impediment is the costs and once the issue of costs can be figured out, then it can be more widely accepted.

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