Robot-Assisted Transabdominal Single-Position Simultaneous Bilateral Pyeloplasty with Hidden-Incision Trocar Layout: Two Cases Experience

Introduction: Owing to the relative rarity and surgical difficulty of bilateral ureteropelvic junction obstruction (UPJO) in adults, simultaneously bilateral pyeloplasty has been rarely reported.1 The robot-assisted system helped urologists to overcome this challenge, but in previous reports, intraoperative changes in position and lateralization were still required to accomplish the operation.2,3 This video aims to sharing two effective cases of robot-assisted transabdominal single-position simultaneous bilateral pyeloplasty combined with the hidden-incision technique.4 Materials and Methods: Perioperative information and patient follow-up results were collected from our Reconstruction of Urinary Tract: Technology, Epidemiology and Result (RECUTTER) database. The procedure is performed in the lithotomy, Trendelenburg, head-down position.5 A trocar layout below the level of the external superior iliac spine line was utilized to achieve the principle of a hidden incision that could be concealed by underwear after surgery. The surgeon followed the procedure of exposing the obstruction site—dissecting the ectopic vessels, renal pelvis, and ureter—V–Y anastomosis: (1) clipping of the posterior wall of the renal pelvis to form a V-shape flap and longitudinal clipping of the posterior wall of the ureter to ensure that the two lengths are the same; (2) a single suture at the lowest end of the split ureter and the tip of the flap, followed by continuous anastomosing of one side of the ureter to the flap; (3) excision of the stenotic segment of the ureter and the redundant tissue of the ureter and renal–pelvic wall; (4) placement of a Double-J stent; and (5) continuous anastomosis of the other side of the ureter and renal pelvic flap to re-establish the pelvic–ureteral junction and to close the renal pelvis—wrapping the mesentery. The contralateral side can be handled similarly without intraoperative position changes and redocking. The operation duration, estimated bleeding, time to discharge, interoperative time for catheter removal, perioperative renal function, and drainage volume in both patients were included in the analysis. Analysis of variance (ANOVA) was used to analyze preoperative, intraoperative, and postoperative changes in estimated glomerular filtration rate (eGFR), and a two-sided p < 0.05 was defined as statistical significance. Results: Both surgeries were completed effectively, with operation duration 319 minutes 13 seconds and 257 minutes 47 seconds, respectively. Both patients had their drains removed on postoperative days 4 and 3 and were discharged from the hospital on postoperative days 6 and 4. No perioperative complications were observed. Both patients were effectively removed from the Double-J stents at 2 months postoperatively. Their postoperative eGFR showed a slight rebound in both cases. Conclusion: Robot-assisted transabdominal single-position simultaneous bilateral pyeloplasty can safely and effectively manage patients with bilateral UPJO with severe hydronephrosis or other symptoms. The hidden-incision technique can improve a patient's quality of life and aesthetic needs after the procedure. Patient Consent Statement:The study was approved by the ethics committee of Peking University First Hospital (approval number: 2020-2283) and individual consent for this retrospective analysis was waived. The patients' perioperative and follow-up data were collected from our RECUTTER database. All authors have no competing interest. All authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Runtime of video: 9 min 59 sec