DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Suspected large right parapelvic cyst with secondary ureteral obstruction.
POSTOPERATIVE DIAGNOSIS: Primary right ureteropelvic junction obstruction.
OPERATION PERFORMED: Robotic right dismembered pyeloplasty with stent insertion.
SURGEON: Jane Doe, MD
ASSISTANT: John Doe, MD
ANESTHESIA: General and local.
INDICATIONS FOR OPERATION: This (XX)-year-old patient presented with right flank pain and a contrast CT appeared to represent a large parapelvic cyst with secondary obstruction of the ureter. This is an unusual configuration, but the CAT scan appeared unquestionably consistent with this. The patient’s pain spontaneously resolved, and a repeat study without contrast showed reduction in the cystic area, and he was counseled on elective watchful waiting with the presumption that the cyst had decompressed. His pain recurred and another CT revealed the same configuration without contrast. He was, therefore, counseled on robotic cyst removal.
DESCRIPTION OF OPERATION: With the patient under general anesthetic, he was placed in the right flank position with a bean bag. The patient was carefully padded. Foley catheter had been placed. An umbilical 1 inch incision was made and peritoneum entered under direct vision and the balloon trocar introduced after suitable preparation and draping. A 30-degree laparoscopy was performed and anatomy was favorable, and two robotic ports were placed alongside the camera port as well as a 5-12 working assistant port. This proceeded uneventfully. The robot was then docked.
The colon was then reflected medially using cautery and scissors. Duodenum was kocherized. The very large cystic area was identified at the original laparoscopy. The first objective was to identify the ureter for safety and for landmark and this was done at the lower pole of the kidney and followed upwards. This tracked along the anterior, inferior edge of the cystic mass and was carefully dissected out. There was dense fibrosis. This ureter eventually was found to enter the large cystic mass itself, and once the ureter had been removed off the lower pole of the cystic mass, there appeared to be peristalsis of the entire mass becoming more and more consistent with a standard UPJO.
At this point, indigo carmine was administered to try and further evaluate this, and after a careful dissection of the entire cystic mass and the UPJ, there was no obvious other remaining cystic structure in the location that the CAT scan had suggested, other than the dilated renal pelvis. The renal parenchyma was carefully inspected, and there was no other cystic structure. I had requested intraoperative ultrasound to further evaluate this, but this was not for repair. We then aspirated with the gallbladder needle at the renal pelvis and this decompressed the entire system, and there was again no further cystic mass in any location.
At this point, the diagnosis was clearly extended congenital UPJ with a high takeoff. The renal pelvis was then completely reduced and the ureter transected well below the fibrotic area, and using 4-0 RB-1 Vicryl sutures, a running spatulated repair was performed. Below the rib cage, an 18-gauge PCNL needle was used to introduce a wire into the abdominal cavity under direct vision, after which a 10-12 dilating sheath was passed over the wire and the wire was passed down the ureter uneventfully. The 10-12 sheath was used to pass a 6 x 24 double-J stent, and the proximal coil was placed in the renal pelvis.
The renal pelvis was irrigated and the toe of the spatulated anastomosis was closed, and the extension of the reduction pyeloplasty was closed with running Vicryl as well. The anastomosis appeared quite satisfactory with 10 times magnification of the robot, and a #19 Blake drain was brought out through one of the robotic ports, the robot undocked, and all ports removed with no bleeding encountered. The fascia was closed with interrupted figure-of-eight, skin edges with subcuticular and Dermabond applied. The patient tolerated the procedure well and no complications were encountered. Sponge and instrument counts were correct. The patient was transferred to the recovery room in satisfactory condition.
