Ureteropelvic Junction Obstruction Secondary To Crossing Vessels-To Transpose Or Not? The Robotic Experience

Main Category: Urology / Nephrology
Article Date: 08 Jun 2009 - 1:00 PDT

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UroToday.com - "Good judgment comes from experience, experience (unfortunately) comes from bad judgment." So the saying goes, but perhaps good judgment can (hopefully) come from carefully done reading of the "experiences" of others.

In this excellent manuscript, the authors report on both the objective (i.e. renal scan) and subjective (i.e. analog pain scores) outcomes of 107 patients undergoing a robotic dismembered pyeloplasty for ureteropelvic junction obstruction (UPJO).

Following the lead of Gill and colleagues, the authors noted that among the 45% of their patients who presented with UPJO and an associated crossing vessel, it was feasible to perform a tension free anastomosis with the standard repositioning of the pelvis anterior to the crossing vessel(s) in only one third of the cases (37.5%). In each of the patients in whom the vessels were not transposed, a standard dismembered robotic pyeloplasty was performed such that there was at least a 1 cm distance between the reconstructed ureteropelvic junction and the crossing vessel. The authors don't mention whether they used any reconstructive measures to fix the vessels in a higher position (e.g. Hellstrom technique).

The results were uniformly excellent with 100% radiographic and symptomatic rate of success. In both groups, differential function improved by 10%, T½ fell below 10 minutes, and mean pain scores were under 1.0 on a scale of 10. Of note, the mean follow-up was just over 1 year in both groups.

The side story here is the 100% success rate in over 100 patients undergoing a dismembered pyeloplasty for UPJO. I am now seeing other groups reporting similarly high triple digit success rates for robotic pyeloplasty. One has to wonder, if the robot is providing the surgeon with better abilities than he or she would otherwise have in performing a reconstructive procedure? While further follow-up at 2 to3 years will be important, perhaps it is time to proceed with intrasurgeon comparisons for pyeloplasty, using a matched controlled retrospective analysis. The results could be most illuminating.

Boylu U, Oommen M, Lee BR, Thomas R
J Urol. 2009 Apr;181(4):1751-5.
doi: 10.1016/j.juro.2008.11.114

Written by UroToday.com Medical Editor Ralph V. Clayman, MD

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