Technical Caveatstips

The technical advantages afforded to the surgeon by the robotic surgical system are readily apparent. It is especially intriguing to experience the ease of intracorporeal suturing by the translation of the surgeon's hand movements via a remote console to the roboti-cally manipulated instruments. With any new technology, trial and error pave the way to a successful operation.

It is always important to have performed a cystoscopy and retrograde pyelogram prior to every procedure. This will help to facilitate your understanding of the uretero-pelvic junction anatomy and clearly define the obstruction. In the pediatric population, it may be easier to place the internal stent prior to the docking of the robot system. But in both children and adults, the indwelling stent should never be in the patient for weeks prior to the surgery. The stent leads to ureteral edema, making every anastomotic repair all the more difficult. If a ureteral stent is in place, we recommend removing the stent at least one week prior to pyeloplasty repair.

When placing a ureteral stent prior to completion of the water-tight anastomosis, it is important to make sure that the guide wire is pushed into the bladder.

The addition of methylene blue into a full bladder with a clamped Foley may aid in the successful placement of the ureteral stent. Fluoroscopy or direct vision of the distal end of the stent in the bladder with a flexible cystoscope may also ensure proper placement of the ureteral stent.

A "hitch stitch" placed at the medial side of the ureter may aid in retraction. This stitch can either be held by the operating surgeon or the assistant, or can be tacked up to the peritoneal wall if necessary. Alternatively leaving some diseased ureter and/or periureteral tissue attached will create a handle for retraction.

The novice robotic surgeon will find the robotic-assisted pyeloplasty to be a wonderful introduction to the robotic surgical system.

The first several cases may be time consuming, but for the surgeon, the greatest advantage is the comfortable working position. Also, the three-dimensional view with

It is likely that the inexperienced laparoscopic surgeon may gain the most from the da Vinci Surgical System.

Although the learning curve for the surgeon may be short (in our experience less than 10 cases), there is a substantial learning curve for the ancillary staff. Many hours of in-servicing may be required and consistency in the assignment of staff to da Vinci robot cases allows for a smooth transition between cases.

It is always important to have performed a cystoscopy and retrograde pyelogram prior to every procedure.

When placing a ureteral stent prior to completion of the water-tight anastomosis, it is important to make sure that the guide wire is pushed into the bladder.

A "hitch stitch" placed at the medial side of the ureter may aid in retraction.

The novice robotic surgeon will find the robotic-assisted pyeloplasty to be a wonderful introduction to the robotic surgical system.

Until extensive experience is gained with the robotic surgical system, it is recommended that the novice robotic surgeon start the robotic-assisted pyeloplasty with a standard laparoscopic technique.

If personnel are not appropriately trained and careful when setting up and taking down the device, complications could theoretically occur secondary to mechanical failures.

easy handling of the instruments will lead to shorter operative times as experience is gained.

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