Robot-assisted pyeloplasty: The way forward.

Over the years, many surgical procedures have evolved from the open approach to minimally invasive laparoscopic and robotic techniques. This evolution replicated the efficacy and safety of the open approach while adding the benefits of smaller incisions, shorter convalescence and a reduced hospital stay. Historically, pyeloplasty has been the gold standard for the management of pelviureteric junction obstruction (PUJO), with the primary objective to prevent renal functional deterioration and relieve symptoms. Since its first description by Schuessler et al. in 1993, laparoscopic pyeloplasty has been widely adopted with a good success rate of 90%–95%. Recent trends show that the use of a laparoscopic approach for pyeloplasty has greatly increased.[1] However, there are technical challenges associated with the laparoscopic approach, as pyeloplasty needs strong laparoscopy experience with advanced laparoscopic skills including intracorporeal suturing and knotting.

Robotic surgery has shown significant advantages over standard laparoscopy. Tremor cancellation, three-dimensional vision and seven degrees of free movement allow the surgeon to optimally perform reconstructive and complex oncological procedures in confined working spaces. The application of robotic technology to laparoscopic pyeloplasty has reduced the steep learning curve and allowed the surgeons not adept at laparoscopy to offer this treatment to their patients. Robotics, with its 'endo-wrist' technology and improved visualization, has helped to reduce the challenges of laparoscopic suturing.[2] Robotic pyeloplasty is possible by both the transperitoneal and retroperitoneal approaches in adults as well as in the pediatric population.[3] Several associated anatomic variations such as lower moiety PUJO, malrotated kidney and crossing lower pole vessels in normal as well as anomalously placed kidneys can be treated. It has also proved useful for the repair of secondary PUJO, a procedure which is considered difficult with both open and conventional laparoscopic approach. Redo pyeloplasty as well as ureterocalycostomy can be performed robotically as a salvage procedure in this difficult situation.[4]

The robotic platform offers all benefits of pure laparoscopy with a much better ergonomics for the surgeon. This leads to a shorter learning curve with the robotic approach even for surgeons without a great deal of experience with laparoscopic pyeloplasty. Prior laparoscopic experience, or lack of it, does not influence one's dexterity while using the robotic platform.[5]

Finally, the pursuit of scarless cosmetic surgery has seen the development of laparoendoscopic single-site (LESS) procedures. These procedures have challenges like triangulation and motion restriction, especially for surgeries such as pyeloplasty that require multiple sutures. The application of robotics to LESS can also reduce the difficulty in performing conventional LESS pyeloplasty.[6]

Despite the advantages of the robotic approach, can it be the first choice access for pyeloplasty? Probably not immediately. First of all, the robotic system is still not widely available in many parts of the world. Even where availability is not an issue, increased cost involved with the use of the robotic platform would be a major hindrance for the patient as well as for the institution to choose robotic over standard laparoscopy. Finally, no particular approach has been shown to be superior to the other in terms of peri-operative outcomes and success rates.[7] This highlights the fact that results of dismembered pyeloplasty depend on the basic technique of performing the surgery and not the approach utilized to perform it.

It would seem unlikely that experienced laparoscopic surgeons who are well versed with intra-corporeal suturing would find any great benefit in shifting from pure laparoscopy to robotic approach. However, we believe that the easier learning curve and improved surgeon's quality of life and the fatigue scores, which are useful for surgeon longevity, could prompt young urologists to adopt the robotic approach, subject to availability of the system.[8]

Robot-assisted pyeloplasty has become widely popular and can be considered the approach of choice in the management of UPJO wherever infrastructure and finances permit.