Preoperative Preparation

Patients undergoing a robotic-assisted pyeloplasty should be subjected to preoperative evaluation and preparation as if they were undergoing an open operative intervention. This includes a search for any comorbidity that may increase the risk of anesthesia. Any urinary infection should be treated, and sterile urine should be ensured at the time of definitive intervention. If upper tract infection cannot be cleared because of obstruction, an internal stent or percutaneous nephrostomy drainage should be placed.

The patient should be counseled as to the risks and benefits of the procedure, including the fact that the success rate of any robotic-assisted approach may be less than that of a standard open operative intervention.

In addition, for any minimally invasive approach, there is always a risk that an open conversion may be possible. Patients should also be apprised of the fact that bleeding requiring transfusion is a risk of the procedure, and a "type and screen" should be part of the protocol.

A bowel preparation is usually recommended especially when robotic surgery is performed by the novice practitioner. Any standard bowel preparation will suffice. In the unlikely event of a bowel injury, this step may ensure a less complicated postoperative course for the patient.

All patients in both the adult and pediatric populations should have radiographic evidence of ureteropelvic junction. This may include ureteropelvic junction on diuresis renography or hydronephrosis with delayed function on excretory urography (IVP). Computed tomography, magnetic resonance imaging, or ultrasound may be helpful for anatomic mapping of the ureteropelvic junction with or without a crossing vessel, but will not always definitively indicate a ureteropelvic junction obstruction.

Finally, a renal split function may be helpful in cases where renal deterioration is suspected. This provides a baseline study to compare with in the future and will also predict the likelihood of a successful repair. The lower the renal function in the obstructed renal unit, the lower the chances of a successful repair.

Newer robot surgical systems have incorporated a fourth arm that can be used as either a second right or a left arm. However, the robotic-assisted pyeloplasty does not warrant a fourth robotic arm, and the protocol is described using a three-arm robot with an assistant.

For the novice, it is recommended that the first 20 cases be performed with laparoscopic assistance until a comfort level is reached with the da Vinci robot.

Once the diseased UPJ and/or crossing vessel are identified, the da Vinci robot is docked into place.

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