Robotic Pyeloplasty Has Advantages

John Schieszer
March 15, 2010

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.