This topic reviews the technique and application of robotic-assisted laparoscopic pyeloplasty (RLP). Open pyeloplasty has been the criterion standard for pyeloplasty, achieving excellent long-term success rates of over 90%,
despite the disadvantages of longer hospital stay, increased postoperative pain, and slower return to normal activities as compared with laparoscopic renal surgery.
Two other forms of surgical options emerged offering minimally invasive techniques. The first was antegrade endopyelotomy through a percutaneous tract.
The second was retrograde endopyelotomy, in which retrograde access is obtained by using fluoroscopy and small-caliber ureteroscopes.
The main attraction of retrograde endopyelotomy is the avoidance of percutaneous access, which allows the procedure to be performed with less morbidity and a shorter inpatient convalescence period or none at all.
The first laparoscopic pyeloplasty was reported in 1993.
Many series showed that laparoscopic pyeloplasty was comparable to open pyeloplasty.
Long-term series with a minimum of 2 years’ follow-up reported excellent success rates (96-98%).
Laparoscopic pyeloplasty also achieved good success (eg, 83% in 36 patients) after previous failed procedures (eg, antegrade or retrograde endopyelotomy, balloon dilatation, and open pyeloplasty).
Despite the low morbidity of the procedure, the long-term results of endopyelotomy could not be compared with those of open or laparoscopic pyeloplasty.
The benefit of quick recovery from surgery after endopyelotomy could also be matched by the minimally invasive laparoscopic approach. For these reasons, endopyelotomy gradually took a smaller role in the first-line management of ureteropelvic junction obstruction (UPJO).
Excellent results notwithstanding, laparoscopic pyeloplasty did not replace open pyeloplasty the way laparoscopic nephrectomy replaced open nephrectomy—mainly because of the steep learning curve required to master advanced laparoscopic skills such as intracorporal suturing, which can be time-consuming and imprecise in the initial learning stages. The development of RLP has reduced the obstacles to learning intracorporeal suturing, which is the main reconstructive step in pyeloplasty. In 2009, RLP surpassed open surgery as the most widely used approach for pyeloplasty in the United States.