V9-11: Robotic Pyelolithotomy and Ureteropelvic Junction Repair in a Cross Fused Ectopic Kidney

Video

Introductions and Objectives
Cross fused renal ectopia is a rare congenital anomaly characterized by unilaterally located fused kidneys. For renal calculous disease in this patient population, shockwave lithotripsy (SWL) has a poor stone clearance rate due to inadequate urinary drainage. Percutaneous access is also difficult due to the intervening spine posteriorly and overlying bowel anteriorly. We report a case of robotic pyelolithotomy and ureteropelvic junction (UPJ) reconstruction in a patient with this anatomic variation.

Methods
Our patient is a 46 year-old male with an L-shaped left-sided cross fused kidney. He also had duplication his fused segment with hydronephrosis of the lower pole moiety suggestive of a UPJ obstruction. He presented with a 1.7 cm, a 1.1 cm and a 6 mm stone that had failed treatment with SWL and ureteroscopy. A stent was placed into the lower pole moiety and the patient was placed in a modified flank position with the left side up. All ports were placed in the midline with 2 assistant ports for retraction. The robot was docked perpendicular to the patient. After identifying the cross fused segment, ureterolysis of the lower pole ureter was performed. Laparoscopic ultrasound was used to identify the renal stones. A vertical pyelotomy in the fused lower pole renal pelvis was created and stones were removed. Ultrasound identified the remaining renal stone in the upper pole moiety of the fused segment. A second pyelotomy was created and the final stone was removed. The UPJ of the lower pole moiety was dismembered and the ureter was spatulated. An Anderson-Hynes pyeloplasty was then completed over our previously placed ureteral stent and the pyelotomies were closed with 3-0 V-loc suture.

Results
The patient tolerated the procedure well and was discharged home on post-operative day 3. Our operative time was 331 minutes with an estimated blood loss of 50 mL. His post-operative creatinine level was 0.85 mg/dl and at one-month follow up, his diuretic radionuclide scan demonstrated no evidence of urinary tract obstruction with a T1/2 of 12.9 minutes.

Conclusions
Robotic pyelolithotomy with ureteropelvic junction reconstruction can be considered in patients with cross fused ectopia and nephrolithiasis who have failed traditional treatment modalities.

Funding: None