Prior to any information about treatment options, we have to keep in mind that for problems occurring in urine drainage through UPJ might be temporary and they may resolve spontaneously in patients 18 months of age or younger. However, in case of an obstruction, and any kidney damage caused by this obstruction, surgery might become essential even if the patient is younger than 18 months. It will be much more appropriate to perform the treatment with Pediatric Conventional Laparoscopic Surgery procedure for babies at this period.

While some babies and kids can get a fast recovery in months despite the UPJ obstruction diagnosed at first place, some do not show any signs of improvement and their condition may start to get even worse. For this reason, children at this age must be followed up closely. Parents must become much more conscious about this. Follow-up process generally consists of measuring the dilation of renal pelvis (hydronephrosis) with periodical ultrasonography.

Surgery is required for patients whose final diagnosis is UPJ obstruction and recovery is not regarded as possible. 

Classical UPJ obstruction surgery consists of removal of the obstructed part of UPJ with open surgery and creating an anastomosis between the ureter and renal pelvis (Image-1). This procedure is called ‘’Dismembered Pyeloplasty’’.

Image-1: UPJ obstruction at kidney outlet related to cross-vein presence, removal of obstructed part via surgery and reanastomosis between ureter and renal pelvis.

 

 

upjOpen Pyeloplasty, just like other renal surgeries, requires an incision below left or right ribs, but this incision is a much bigger one when compared to the incisions made for other close surgery procedures. This operation is completed around 2-3 hours, with success rates around 95%. Post-operative hospitalization periods depend on patient age and the type of drainage tubes placed.

Pyeloplasty surgery via laparoscopic technique, which has come to the fore in recent years, is performed laparoscopically, meaning closely – through holes. Surgical procedure is exactly the same as open pyeloplasty. However, while performing this surgery with laparoscopic technique, patients are being operated through 3 or 4 small holes, instead of a big surgical incision. Pyeloplasty surgery performed via this technique is called ‘’Laparoscopic Pyeloplasty’’. When this procedure is performed with daVinci Robot, whose arms are placed into body through similar holes, it is called ‘’Robotic Pyeloplasty’’. In a similar way, this procedure is completed around 2-3 hours, with success rates higher than 95-97%. Post-operative hospitalization period is around 1 or 2 days.

daVinci Robotic Pyeloplasty surgery is also performed through 3-4 small holes as is the case with laparoscopic surgery. However, although it is thought that there are no significant differences between ‘’Robotic Surgery’’ and ‘’Conventional Laparoscopic Surgery’’, daVinci Robotic System offers our patients a surgery performed with 3 dimensional, high resolution vision system that magnifies the view 10-15 times, and with robot arms that eliminate tremors and can maneuver multi-directionally in body just like a hand. These technologic advantages provided by steady robot arms and three-dimensional high definition view offer the surgeon an opportunity to make millimetric sutures from many different angles during pyeloplasty surgery, which is a plastics surgery performed on millimetric scales at the level of kidney outlet. Having a chance to perform the surgery in millimetric scales is a very important point in terms of surgical efficiency.

Scientific researches show that there is no difference between Robotic Pyeloplasty and laparoscopic technique in terms of success rates. However, Robotic Pyeloplasty has some advantages over open surgery technique:

What are the most significant advantages of Robotic Pyeloplasty?

Most significant advantages of ‘’Robotic Pyeloplasty’’:

  • Not a big incision is required as in open surgery; operation is performed through small holes
  • Operation is performed with larger and clearer view of area
  • High resolution 3-dimensional imaging quality
  • Advantage of depth perception provided by 3-D imaging
  • Making millimetric sutures from different angles are possible thanks to small robotic arms that are steady and capable of 540 degrees of articulation 
  • Robotic arms eliminate tremors
  • Cross-vein presence can be found out clearly and be treated
  • Anastomosis procedure is made with assistance of magnified imaging system (with 10-15 times magnified view)
  • Less post-operative pain when compared to open surgery
  • Post-operative hospitalization period is shorter
  • Rapid improvement –  recovery in a short time
  • Better cosmetic results when compared to open surgery

If the kidney has swollen seriously or if there is a cross-vein presence at the level of UPJ obstruction, first surgical option should be ‘’Laparoscopic Pyeloplasty’’;  if the surgeon is not experienced in laparoscopic technique, first option might be ‘’Robotic Pyeloplasty’’ when positive effects of technologic advantages are considered. 

Robotic Pyeloplasty is performed through the peritoneum that covers intestines in the abdomen (transperitoneally). Conventional laparoscopic pyeloplasty surgeries have been performed by Prof. Dr. Tibet Erdogru since 2005 with 95% success rate; and more than 70 cases have been presented in a great number of scientific meetings. The reason for not reaching the intended success rate in other patients is not the technique itself, but performing the operation with an intend to save the kidney whose disease is in advanced period and serious renal dilation is present. Above mentioned technologic advantages provided by ‘’daVinci Robotic System’’ have been combined with experiences gained while performing a reconstructive – plastics surgery like Pyeloplasty through small holes of 8mm, with a millimetric and impeccable precision, and the reflection of this combination to our treatments has gained acceptance as one of the most up to date treatment approaches.

Our success criteria for Pyeloplasty:

  • Improvement in renal dilation or its recovery
  • Complete relief of pain
  • Problem-free renal drainage should be observed by scintigraphy

 

Robotic Surgery Series – UPJ Obstruction

 

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