Most patients with ureteropelvic junction obstruction (UPJO) have a large anterior extra-renal pelvis which is easily accessible during conventional robotic pyeloplasty. In contrast, for patients with intrarenal/posterior pelvises, the pelvis is relatively inaccessible, making the surgery harder.
Among the 100+ robotic pyeloplasties I have done, I have encountered 3 or 4 intrarenal/posterior renal pelvises, all of them on the right side:
With the usual extrarenal pelvis, dissection begins at the pelvis, whereas with intrarenal/posterior pelvises dissection is started at the proximal ureter; the ureter is then followed all the way to the renal pelvis, which is usually under the hilum:
For the first 2 cases, I used an assistant port in the left lower quadrant to keep all the trocars hidden in the bikini line:
The assistant port is suboptimal in this location for posterior pelvises, as it tends to be in the way of the other instruments and its location is not ideal for anterior retraction of the lower pole of the kidney.
For the last 2 cases, I started first with the usual Hidden Incisions Robotics port placement using 3 trocars:
I made an attempt to do the surgery with these 3 trocars but once I started using one of my working hands mostly for retracting –operating with one hand –, I placed a 4th robotic trocar in the subxiphoid area to be used with the forth robotic arm for retraction:
The subxiphoid area is a great location for the 4th arm as it does not move or gets bumped by other instruments, which used to be the case with the left lower quadrant assistant port. The 4th arm converts a very difficult pyeloplasty, into the pyeloplasty that you are used doing:
The case from the pictures above took 2 hrs and 7 minutes from incision to closing.
I found 2 case reports of laparoscopic pyeloplasty for intrarenal pelvises. Campbells had nothing on intrarenal pelvises.
In this case report, the authors described a 4 hr insufflation-time laparoscopic dismembered pyeloplasty for an adult with an intrarenal pelvis. The authors mentioned that although a Y-V repair was considered acceptable for intrarenal pelvises, they decided to do a dismembered pyeloplasty due to better results reported in the literature with dismembered versus Y-V pyeloplasties. These authors also resorted using 4 ports instead of their usual 3 ports, due to the need to retract the lower pole of the kidney — as in our case.
Another case report, this time in a child, described a laparoscopic pyeloplasty on an intrarenal pelvis in a 12-year-old. The case took 5 hrs and 20 minutes.
Initial hidden incision port placement happens to also be ideal for robotic pyeloplasties with intrarenal of posteriorly located pelvises, as it allows the space necessary to add a 4th robotic arm for seamless retraction, converting a difficult pyeloplasty into a standard pyeloplasty.