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Pyeloplasty

Robotic technique

1. Cap nephrostomy tube (if present) to distend renal pelvis
2. Position, prep, drape, and place ports similar to a nephrectomy
3. Medialize colon and identify hilum, be aware of lower pole crossing vessels
4. Dissect ureter (taking care not to injure blood supply) and expose renal pelvis
5. Transect ureter from renal pelvis and bring anterior to crossing vessel (if present)
6. Spatulate ureter laterally until normal lumen, make sure renal pelvis adequately spatulated medially
7. Place vicryl stitches x2 at inferior apex, run one posteriorly and the other anteriorly
8. Prior to closing renal pelvis, place stent over wire through anterior abdominal wall (angiocath) or via assist port, ensure proximal coil seats in renal pelvis
9. TIP: consider removing PCN before/during stent placement
10. Tie vicryls to each other, may require a third stitch to close redundant renal pelvis
11. Place drain near surgical site

Postoperative plan

• KUB: obtain in PACU to confirm stent position
• Drain plan: check Cr level if output >100mL overnight, otherwise remove foley on POD#1 rounds, monitor drain output, remove if < 100mL otherwise check Cr level
• Stent plan: remove in 3-4 weeks
• Follow-up: can check renal US (patient may always have residual hydronephrosis), NM renal scan (assess for obstruction), or clinical symptoms, can assess at 6wks and 6mo, then PRN

Ureter reimplant

Robotic ureteroneocystotomy technique

Open Boari Flap technique

1. Position patient supine, arms out, flex bed to open abdomen, cap PCN (if present) to distend upper tract, place foley on field
2. Perform midline laparotomy, enter peritoneal cavity, place bookwalter retractor
3. Identify ureter medial to gonadal vessels, anterior to psoas muscle, and superior to iliac branch point
4. Free up ureter while maintaining blood supply and cut proximal to stricture
5. Identify urachus, free from abdominal wall, then trace inferiorly to free bladder from abdominal wall, avoid injury vas deferens
6. Distend bladder with 150mL and measure distance from ureteral stump to bladder dome
7. Demarcate flap that is same length and width, then incise in U-shape (sharp dissection on mucosa)
8. Hitch flap to psoas tendon using 2-0 PDS simple interrupteds x3-4, place stitches longitudinally to avoid injuring genitofemoral nerve
9. Tunnel ureter through flap (if desired), spatulate, and anastomose to mucosa with 4-0 vicryl running
10. Place appropriately sized stent over a wire, removing PCN prior to deploying stent
11. Close bladder mucosa with 3-0 vicryl, close outer detrusor/peritoneum with 2-0 vicryl
12. Leak test bladder with 150mL
13. Place penrose drain near surgical site via separate stab incision, suture to skin with nylon
14. Close fascia with #1 PDS x2, then close subcutaneous tissue and close skin with staples

Robotic ureteroureterostomy

1. Position patient in supine lithotomy, place in trendelenberg and consider airplaning the table with surgery side up (to assist with passive retraction)
2. Place stent cystoscopically, will help to identify healthy ureter
3. Place ports with usual technique, can either place in straight line or diagonal line to triangulate towards ipsilateral pelvis
4. Usually easiest to identify ureter crossing over iliacs, may need to retract ovary away from midureter
5. Duplicated ureters will be present in common sheath, and stent can be palpated
6. Incise recipient ureter longitudinally on superior surface
7. Cut donor ureter distal to anastomosis point, then spatulate proximal end
8. Suture donor ureter to recipient, can use 3-0 V-loc or interrupted vicryl stitches
9. Consider closing distal ureteral end if patient has reflux otherwise okay to leave open
10. Place drain and leave foley

Pediatric reimplant

Cohen Crosstrigonal technique

1. Position supine, arms tucked, prep abdomen and genitals
2. Pfannenstiel incision along Langer lines, incise down to fascia
3. Separate fascia off underlying muscle
4. Separate rectus muscles at linea alba almost to pubis, retract laterally with Denis Browne ring
5. Place stitch on either side of midline incision, then make vertical cystotomy
6. Pack bladder dome with moist raytec x3, retract edges superiorly and laterally
7. Identify ureters at trigone, beware of ureteral duplication
8. Place holding stitch past distal portion of ureteral orifice
9. Incise mucosa with cautery (cut), ensure enough room around orifice for suturing
10. Dissect away underlying tissue from ureter, obtain enough length that the ureter can reach the skin without tension
11. Create the cross-trigonal tunnel with a right-angle retractor, grasp the ureteral retraction stitch and pull through the neohiatus
12. Stitch the ureteral apex with 4-0 vicryl x1, then stitch in the rest of the ureter with 6-0 vicryl
13. Close the mucosa over the dissection site with ***
14. Remove the raytecs, close the bladder in two layers, start towards bladder neck, close one layer, then continue the same stitch on the outer layer
15. Close the fascia with ***, scarpas with vicryl interrupted x3, and skin with subcuticular stitch, then apply dermabond