Robotic Pyeloplasty of a Pelvic Kidney with Ureteropelvic Junction Obstruction

Introduction: The incidence of an ectopic pelvic kidney has been approximated at between 1 in 2200 and 1 in 3000. Often times, these kidneys are malrotated and may be associated with anomalous blood supply. Ureteropelvic junction obstruction (UPJO) has been reported to occur in 22% to 37% of ectopic kidneys and classically requires an open surgical approach for repair. In this video, we present a unique case of a patient with UPJO of an ectopic pelvic kidney, which was managed with robotic pyeloplasty. Materials and Methods: Our patient is a 46-year-old male who presented for evaluation of chronic suprapubic and right flank pain. A computerized tomography (CT) study of the abdomen and pelvis was notable for an ectopic right-sided kidney located in the true pelvis exhibiting significant hydronephrosis compatible with UPJO. A renal scan supported the diagnosis and was notable for split renal function of 20% on the right and 80% on the left. The patient was offered a robotic pyeloplasty as a definitive treatment of his pathology. He was brought to the operating room where a retrograde study was found to be suggestive of high insertion of the ureter. An 18-cm/4.5F Double-J stent was placed, after which the patient was positioned in a steep Trendelenburg position, similar to that employed during a robotic prostatectomy. A three-arm robotic prostatectomy trocar template was used. The peritoneal space was insufflated and the retroperitoneum overlying the kidney was exposed. The renal pelvis and ureter were identified and exposed. A high insertion of the ureter into the renal pelvis was confirmed. The UPJ was dismembered and a side-to-side anastomosis of the ureter to the dependent portion of renal pelvis was performed. The dilated renal pelvis was not reduced. The peritoneum was reapproximated and a drain was placed. Estimated blood loss was less than 50 mL. Results: Postoperative course was uncomplicated and the patient was discharged on postoperative day 2. He underwent stent removal 4 weeks later. Follow-up CT and renal scans 8 months postoperatively showed marked resolution of the hydronephrosis. There was no evidence of obstruction and a modest improvement in the kidneys split renal function was noticed. The patient remained asymptomatic. Conclusion: Repair of UPJO of an ectopic pelvic kidney poses a surgical challenge often times requiring an open approach. In this video, we demonstrated the feasibility of a robotic pyeloplasty, while focusing on the techni