V09-07: Six-week-old Infant Robotic Pyeloplasty: Key Points for Safety and Proficiency
Ureteropelvic junction obstruction (UPJO) is one of the most common pediatric urologic congenital anomalies. Anderson-Hynes dismembered pyeloplasty has been the gold standard for the intervention of this pathology. Nowadays, robotic surgery has provided a safe alternative to manage these patients with minimally invasive surgery and, even though the procedure is frequently performed by pediatric urologists across the US, there is still a steep learning curve to perform infant robotic pyeloplasty. We aim to describe a robotic-assisted laparoscopic pyeloplasty in a 6-week-old patient with grade 4 hydronephrosis and UPJO in addition to key technical points for safety and proficiency.
The crucial points are patient positioning, proper port placement; particularly the inferior working ports, given the close proximity to the bladder, instrumentation and docking and the inherent bowel distension that children usually have. We present a robotic pyeloplasty in a 6-week old infant with UPJO. The patient was placed in a lateral position, close to the edge of the table. With an open Hassan technique approach, a 12-mm umbilical camera port and two 8-mm ports were placed in the midline in addition to a 5-mm assistant port that was positioned on the lower midclavicular line. There was a distended bowel, therefore an orogastric tube was placed to improve visualization and avoid bowel injury. The Gerota's fascia was incised and the pelvis was hitched with a subcutaneous suture. Then, the narrow ureteropelvic junction was recognized and the pelvis was transected just below the renal hilum vessels, which was followed by ureter spatulation. Ultimately, the anastomosis of the posterior wall with the spatulated ureter was performed in a continuous fashion and subsequently, a double J stent was placed percutaneously to complete the anterior wall anastomosis.
The patient tolerated the procedure well and was discharged on postoperative day 2 without any complications. Operative time was 143 minutes and, estimated blood loss was found to be less than 5 mL. The Foley catheter was removed prior to discharge. At 1 month follow-up, the patient had well healed abdominal surgical incisions, the double J stent was removed and, his renal bladder ultrasound scan showed improvement of the hydronephrosis.
We emphasize the key points for safety and proficiency when performing a robotic infant pyeloplasty, given our long-term institutional experience doing robotic surgery in such young patients to optimize outcomes and prevent complications.