At the Pacific Rim Robotics Conference last month there was a session on robotic pyeloplasty. It was held on Saturday afternoon, the last day of the conference, and featured a lecture by Dr. Elspeth McDougall and a live broadcast of the operation from UC Irvine performed by Dr. Ralph Clayman. Dr. McDougall described the operation as they perform it at UCI and then showed their results in about a half dozen cases, including a bilateral pyeloplasty in a horseshoe kidney. The outcomes were at least as good as with open, laparoscopic or endoscopic pyeloplasty techniques. The steps that she described in her lecture were those that we would see Dr. Clayman follow in the live demo that was presented imediately after her talk. I was interested because I have done about a half dozen or more myself and my partner has done several as well.
What struck me about their technique was that both Dr. McDougall and Dr. Clayman still do almost the entire operation with straight, handheld instruments and only bring in the robot for the purpose of sewing the pyeloplasty once the pelvis has been completely dissected. I simply could not understand the logic, especially when during the live demo a crossing vein and artery were encountered. We could hear Dr. Clayman, as he struggled to deal with the vessels, complaining several times that if he only had a decent right angle laparoscopic dissector he could get under the vessels and proceed with the operation. All I could think of was that any one of a number of the Endowrist instruments would make excellent right angle dissectors. In fact, I thought the entire operation could have been done quicker with the da Vinci than with the laparoscopic instruments. But when I asked Dr. McDougall, who continued to add to the commentary from the podium during the case, why they did it that way instead of using the da Vinci I was told that that was just the way they felt was best. I didn’t find that a very satisfying answer.
Now I am not in a position to question two university professors and leaders in the field with far more laparoscopic experience than me, but I think it is that grounding in laparoscopy that is preventing them from making a break and going to a fully robotic procedure. There was nothing in the presentation that would cause me to change back to laparoscopic dissection.
For a urologist starting robotics, a dismembered pyeloplasty is an excellent first or at least early case. The anatomy is in most cases straightforward enough that it shouldn’t pose any major problems and the dissection gives the surgeon a chance to get a good feel for the instrument. But I would do the whole thing robotically, start to finish.