open pyeloplasty surgery has traditionally been the standard of care for ureteropelvic junction ( upj ) obstruction in adults , achieving success rates of 90% to 100% . in an effort to develop a less invasive procedure ,
percutaneous antegrade and ureteroscopic retrograde endopyelotomy procedures were developed over 20 years ago . despite lower success rates of 61% to 89% and an increased risk for perioperative hemorrhage , these endoscopic procedures gained favor for their minimally invasive approaches .
this procedure maintained the benefits of endoscopic approaches , including decreased postoperative pain , short length of hospitalization , and reduced postoperative recovery time , while demonstrating comparable success rates to the conventional open approach .
however , the technical challenge of reconstruction limited this procedure to select medical centers with laparoscopic surgeons with advanced skills .
the introduction of robot - assisted laparoscopic surgery has widened the surgical dimensions for minimally invasive surgery . specifically , the availability of the da vinci robotic surgical system ( intuitive surgical , sunnyvale , ca ) has facilitated complex reconstructive and laparoscopic procedures .
the benefits imparted to the surgeon include enhanced 3-d visualization , improved dexterity , greater precision , increased range of motion and reproducibility .
we review the initial series of 3 experienced laparoscopic surgeons at several new york city medical centers performing the robot - assisted laparoscopic anderson - hynes dismembered pyeloplasty .
we performed a review of 38 consecutive patients who underwent robot - assisted laparoscopic pyeloplasty between april 2001 and january 2004 at 3 new york city medical centers .
all 38 patients had symptoms or radiographic confirmation , or both , of ureteropelvic junction obstruction with either a diuretic renal scan or an ivp revealing hydronephrosis and delayed renal function .
all but 2 patients presented with primary ureteropelvic junction obstruction of which 10/38 ( 26.3% ) had crossing vessels identified at the time of surgery .
one patient had a renal anomaly of a horseshoe kidney , a second patient had a nonfunctioning contralateral kidney , and 2 more patients had renal calculi associated with the ureteropelvic junction obstruction .
the da vinci robotic surgical system ( intuitive surgical , sunnyvale , ca ) available at all 3 of our institutions consists of 2 interactive robotic arms , a camera arm , a 3-dimensional imaging system , and a virtual control chamber .
the patient is placed in a lateral or semi - lateral decubitus position and 3 laparoscopic ports [ 8-mm ports ( intuitive surgical , sunnyvale , ca ) , 12-mm disposable port ( ethicon , cincinnati , oh ) ] are placed in a  c  configuration ( figure 1 ) .
the ports are placed at least a hand length apart or a minimum of 9 cm away from each other to avoid problems with the working arms of the robot .
the beginning portion of the operation is performed as a standard transperitoneal laparoscopic approach . on the left side ,
the descending colon is displaced medially to gain access to the upj . on the right side ,
the peritoneum is incised from the liver attachments down to the iliac vessels and parallel to the ascending colon , allowing identification of the upj between the lower pole of the kidney and the inferior vena cava .
extensive dissection of the proximal ureter is avoided to maintain the vascular supply to the ureter and upj .
once the diseased upj or crossing vessel , or both , is identified , the da vinci robot is docked into place .
four laparoscopic ports ( two 8-mm ports [ intuitive surgical , sunnyvale , ca ] and two 12-mm disposable ports [ ethicon , cincinnati , oh ] ) are placed in a 
depending on surgeon preference , the camera consisting of a 0 or 30 lens is placed through the disposable 12-mm port at the umbilicus .
the robot arms are each placed through the 2 reusable 8-mm ports . at this time , a fourth port or assistant 's port is placed in the lower infraumbilical area in a position contralateral to the operative side .
one surgeon prefers to place this fourth port at the time of the initial port placements .
a 12-mm disposable port allows the assisting surgeon to introduce and retrieve sutures , aid in retraction , and perform suctioning .
robotic instruments used include needle drivers , debakey forceps , and potts scissors . in performing an anderson - hynes dismembered pyeloplasty , the renal pelvis is circumferentially transected above the upj ( figures 2a and 2b ) , and the proximal ureter is spatulated laterally .
, the current preference is to spatulate the ureter using the da vinci potts scissors . in the case of crossing vessels ,
the ureter and renal pelvis are transposed to the anterior side of the vessel before initiation of the anastomosis ( figure 2c ) .
stones were either grasped out of the renal pelvis by using a laparoscopic grasper or passing a flexible cystoscope through the assistant 's port and then using a stone basket to collect the stones .
anderson - hynes dismembered pyeloplasty is the procedure of choice for robot - assisted cases .
( a ) dissection of the proximal ureter and ureteropelvic junction reveals a crossing vessel .
( c ) after spatulation of the ureter laterally a posterior anastomosis is performed with running or interrupted sutures .
( d ) a tension - free , watertight repair is achieved with an internal stent previously placed ( not shown ) .
the anastomosis was begun with an absorbable suture placed through the apex of the spatulated ureter and at the most dependent portion of the renal pelvis .
if redundant pelvis tissue was excised , the remaining pyelotomy incision was closed using additional sutures .
an indwelling ureteral stent is placed in an antegrade fashion over a guidewire and under direct vision .
the wire is then passed down the ureter in an antegrade fashion , and the ureteral stent is passed over the wire .
alternatively , a 16-gauge angiocatheter can also be introduced into the abdomen , allowing a straight access for the wire to pass into the proximal ureter and bladder .
the distal coil is positioned within the bladder , and the proximal coil is positioned within the renal pelvis .
the foley catheter is clamped 1 hour earlier to distend the bladder and thus allow the ureteral stent to pass more easily into the bladder .
in addition , indigo carmine is instilled into the foley catheter to observe for backflow into the proximal ureter . with the ureteral stent in place , the anterior anastomosis
a drain is placed and then exits the patient via one of the laparoscopic 8-mm ports . in some of our earlier cases ,
the indwelling stent was placed before surgery , but it is believed that this made the transection and repair of the upj more difficult secondary to edema .
correct placement of the distal coil of the ureteral stent into the bladder was also verified with either intraoperative fluoroscopic imaging or a postoperative abdominal x - ray . the total operative time and suturing time
the suturing time was calculated on the actual time that the anastomosis was started and then finished using the da vinci robot .
patients were scheduled for follow - up at 4 weeks to 6 weeks for stent removal .
success was defined as improvement of symptoms related to the previous renal obstruction and improved function on diuretic renal scan .
a total of 38 patients ( 21 females and 17 males ) underwent a robot - assisted laparoscopic anderson - hynes dismembered pyeloplasty .
average patient age was 39.3 years ( range , 15 to 69 ) , and average length of hospitalization was 69.6 hours ( range , 28 to 310 ) .
mean blood loss was 77.355.3 ml . the average use of intravenous morphine during hospitalization was 26.5 mg ( range , 0 to 162 ) .
a mean follow - up of 12.2 months revealed that 36/38 ( 94.7% ) patients were unobstructed based on symptoms and radiographic studies .
this patient started with only 15% renal function on the affected side and never recovered function after the robot - assisted pyeloplasty .
ultimately , a laparoscopic nephrectomy for a nonfunctioning renal unit was performed 3 months later .
a second patient acquired an asymptomatic mild narrowing at the reconstructed anastomosis and was treated with a laser incision of the stricture .
although the patient did not have a documented functional obstruction , it was believed that the patient would develop one in the future .
this patient is currently asymptomatic and has a functionally unobstructed renal unit by diuretic renal scan .
in addition , stones were sent for analysis and were found to be composed of calcium oxalate .
no intraoperative complications occurred , and no open conversions were necessary . four postoperative complications ( 10.5% ) occurred in our series , 3 of which were minor including 1 patient with a urinary tract infection and 2 patients developing pyelonephritis .
the last complication occurred in an early case that involved a 310-pound patient who developed a gluteal compartment syndrome after a prolonged procedure of over 300 minutes . the time to clear liquids was 17.3 hours ( range , 4 to 42 ) and regular diet was 35.7 hours ( range , 20 to 66 ) .
the foley catheter was removed on average 2.4 days after surgery ( range , 1 to 5 ) .
the jp drain was removed shortly thereafter on average of 2.7 days ( range , 1 to 6 ) .
open and endoscopic management of the obstructed upj is being challenged by long - term data from laparoscopic pyeloplasty series .
laparoscopy can address both intrinsic and extrinsic causes of obstruction in a manner similar to that of the open approach .
one of the largest published series of 100 laparoscopic pyeloplasty repairs reveals that the authors were able to perform their repairs in an average of 252 minutes .
successful outcomes were seen in 96% of their patients with a mean clinical and radiographic imaging follow - up of 2.7 years and 2.2 years . according to jarrett et al ,
the difficulty with the laparoscopic approach is that it is technically challenging and a potentially lengthy surgical procedure due to the high proficiency level required for intracorporeal suturing . with experience
, the operative times and learning curve can be reduced to operative times similar to those with open procedures .
several experiences with robot - assisted laparoscopic pyeloplasty have demonstrated the feasibility of this technique in providing improved surgical dexterity and decreasing operative times .
procedures performed with the da vinci robot resulted in overall decreased operative times when compared with those of standard laparoscopy .
gettman et al also reviewed 9 patients who underwent laparoscopic anderson - hynes pyeloplasty with the da vinci system .
the total mean operative time was 138.8 minutes ( range , 80 to 215 ) , of which the mean suturing time was 62.4 minutes ( range , 40 to 115 ) .
estimated blood loss was less than 50ml in all cases , and the length of hospitalization averaged 4.7 days ( range , 4 to 11 ) .
although no intraoperative complications occurred , 1 patient ( 11.1% ) required postoperative open exploration to repair a persistent renal pelvis defect . at short - term follow - up of 4.1 months ( range , < 1 to 8 months ) ,
all procedures were successful on the basis of the subjective and radiographic data . in this
series , robot - assisted laparoscopic pyeloplasty resulted in favorable overall operative times , suturing times , and short - term success rates . in our series ,
all 3 surgeons were able to reduce their operative times ( skin to skin ) from an average of 283.3 minutes for the first 5 cases to 192.0 minutes for the most recent 5 cases ( p<0.001 ) .
as even more experience is gained with this procedure , it is likely that this operating time can be reduced even further .
in addition , all 3 surgeons preferred to start the case with standard laparoscopic techniques . reasons for this include : 1 ) mobilization of the colon , duodenum , liver , spleen , or pancreas is more easily performed with laparoscopic instruments .
2 ) being at teaching institutions , the laparoscopic portion allows all members of the surgical team to be involved with the surgery .
3 ) during the laparoscopic portion , the surgical staff may set up the da vinci robot .
this repair is the gold standard for open pyeloplasty repairs , and the robot allowed us to duplicate this procedure in the most complicated cases .
it is likely that the inexperienced laparoscopic surgeon will gain the most from the da vinci surgical system . besides the experience required to perform complex reconstructive procedures , standard laparoscopic surgery is also handicapped by the reduction in the range of motion due to a fixed trocar position determining the angle of the working field .
the robotic instruments are designed with 7 degrees of motion that mimic the dexterity of the human hand and wrist .
each instrument has a specific surgical mission , such as clamping , suturing , and tissue manipulation .
in addition , 3-d vision is afforded to the surgeon rather than the 2-dimensional view in standard laparoscopy .
other advantages include potential loss of tremor , decreased trauma to the patient in comparison with trauma in open procedures , and comfort for the surgeon .
disadvantages include the lack of tactile sensation , and thus visualization of anatomic landmarks is the key to successfully completing the operation .
the surgeon is away from the operating table , and therefore must depend on an experienced assistant .
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 .
finally , the cost of the da vinci robot is always a consideration . an initial investment of over $ 1,000,000 and subsequent running costs of between $ 80,000 to $ 100,000 a year , may not make this procedure feasible at many centers .
however , as the robotic prostatectomy procedure becomes more popular , the da vinci robotic surgical system may become more readily available at many institutions .
the initial results of this procedure are encouraging , but long - term success rates with follow - up will be needed .
there is a short learning curve allowing this technique to be easily adopted by motivated surgeons and not just laparoscopically trained surgeons .
unfortunately , the cost of acquiring and maintaining a da vinci robot system may limit the implementation of this procedure at many institutions .
 objective : advanced laparoscopic skills limit the implementation of laparoscopic pyeloplasty to centers with extensive experience . 
 the introduction of robotic technology into the field of minimally invasive surgery has facilitated complex surgical dissection and genitourinary reconstruction . 
 we report our experience with robot - assisted laparoscopic pyeloplasty using the da vinci robotic surgical system at 3 new york city medical centers.methods:a review of all robot - assisted laparoscopic anderson - hynes dismembered pyeloplasty cases in 38 patients ( 21 females , 17 males ) between april 2001 and january 2004 was performed . 
 all patients had symptoms or radiographic evidence of ureteropelvic junction obstruction . 
 robotic assistance with the da vinci robotic surgical system was used after preparation of the ureteropelvic junction with a standard laparoscopic approach.results:the average patient age was 39.3 years ( range , 15 to 69 ) . 
 the mean operative time and suturing time were 225.659.3 minutes and 64.214.6 minutes . 
 the average estimated blood loss was minimal at 77.355.3 ml . 
 the mean length of hospitalization was 69.6 hours ( range , 28 to 310 ) . 
 the average use of intravenous morphine was 26.5 mg ( range , 0 to 162 ) . 
 no intraoperative complications occurred , and open conversions were not necessary . 
 a mean follow - up of 12.2 months revealed a success rate of 94.7% with 2/38 patients requiring further treatments.conclusions:this combined multi - institutional series reveals that robot - assisted pyeloplasty with the da vinci surgical system is safe and reproducible . 
 these intermediate results appear comparable to results with open and laparoscopic pyeloplasty repairs . 
INTRODUCTION
METHODS
RESULTS
DISCUSSION
CONCLUSION